Readiness Exam Questions NCLEX-RN

Who can help a parent when the nursing diagnosis is "at risk for the lack of parental bonding related to the lack of parenting skills?

A competent contemporary who has had children

What is glaucoma?

A condition characterized by increased intraocular pressure and progressive vision loss.

How much do baby's gain every year?

A healthy child double half year and triple weight first year. By second year baby should be 4 times birth weight

What kind of patient should you start utilizing the advance directive?

A patient with brain injury that is irreversible and is unable to make decision for themselves. Terminal persistent vegetative state.

Difference between kernig's sign and brudzinski?

Kernig's: Pain occurs on the extension of the knee Brudzinski: stiffness in the neck is flexed towards the chest causing that patients hips and knees to flex.

What happens to patient acid base balance when client reports taking "three rolls of calcium carbonate" (TUMS) in the past eight hours to treat indigestion?

Patient will be metabolic alkalosis. Its alkalotic

What is the nurse first action when hearing inspiratory stridor after suspecting an upper airway obstruction?

Perform the Heimlich maneuver

What should the nurse do when a foreign body enters one of the patients eye?

Place an eye shield over eye. Should be protected from further damage, may be necessary to cover unaffected eye also since they move simultaneously.

Where do place the pillow when examining the right breast?

Place the pillow under the same side shoulder (ipsilateral) while lying down

What should the nurse educate the client on buccal medication administration?

Placed between gums and cheeks. Cheek area has many capillaries that allow the medication to be absorbed quickly without having to pass the digestive system. Stinging may occur depending on the med and if swallowed could be inactivated by gastric secretions.

What is the Guthrie's test?

Positive test (bad sign) indicates decreased metabolism of phenylalanine (metabolic disorder), leading to phenylketonuria. The normal level in newborns is 0.5-1. Guthrie test detects levels greater than 4. Only fresh HEEL blood can be used for this test, The main objective for diagnosing and treating this disorder is to prevent cognitive impairment. A lack of protein intake can interfere with the test. Most reliable after the baby ingest a source of protein. Usually performed no later than 6-7 days after birth.

What is prednisone? What S/S can the nurse expect after client has taken it for two months?

Prednisone is a steroid. Side effect of prolong use is decreased wound healing, hypertension (due to fluid and sodium retention) and moon face (due to fat distribution from prolong steroid use). Facial and body hair will increase with prolong steroid use as well and weight gain.

What kind of education/ teaching should the nurse include about LITHIUM?

Provide safety measure especially when ambulating Ensure patient has an adequate intake of salt and fluids. The kidneys reabsorbs more lithium when salt and hydration is low --> lithium toxicity Make sure to take lithium with food or milk to minimize GI upset Lithium causes dryness in the mouth, nurse should provide sugarless lozenges (cough drop) for client to suck on.

Two nurses are taking an apical-radical pulse and not a difference in the pulse rate of 8 bpm. The nurse document this difference as:

Pulse deficit: Counting pulse at the apex of the heart and at the radial artery simultaneously is used to assess the apical radial pulse rate. A difference between the apical and radical pulse rates is called the pulse deficit.

NPO if have pancreatitis because?

Reduce pancreatic enzyme from eating away your pancreas cause there might be a blockage. Also called autodigestion. Keep NPO and empty so it allow some time for healing. Can be painful.

Which lab test do suspect the HCP to prescribe for a patient with heart failure?

B-type natriuretic peptide (BNP). Elevations indicate worsening of heart failure as it is indicative of fluid retention.

Risk factors for otitis media includes

Contacts with siblings Daycare Season of the year

Patient diagnosed with acute heart failure, what prescription should the nurse question?

Fluids such as NS at 125 mL/hr Risk for fluid overload.

What is pulmonary stenosis?

Narrowed and stiff pulmonary valve.

Patient who is underweight, what should the nurse implement?

Provide additional high protein and calorie shake.

What is serotonin syndrome?

(Everything is increased) Serotonin in the body is good and it helps stabilizes our mood/ feelings and happiness. Serotonin syndrome is too much of the hormone. Serotonin syndrome: increased heart rate, sweating, dilated pupils, tremors, twitching, hyperthermia, agitation, confusion, disorientation, hallucinations Rare and life-threatening event

Domestic violence and the violence cycle. Patient says "this is the last time he will hit me!" Nurse response demonstrated understanding of violence cycle:

"You are greatest risk when you leave" The risk of death or injury is highest at the time the abused person decides to leave the abusive relationship.

What is captopril and how can it affect people planning to get pregnant?

-pril (Ace inhibitor) it should not be taken during pregnancy because serious harm to the unborn baby.

What is given to a client with herpes varicella zoster?

-vir drugs such as acyclovir

What is sucralfate and what should you do if it is given with another medication?

sucralfate should be taken 30 minutes AFTER administering another med. Sucralfate coats the stomach lining and will be harder for the body to absorb meds after taking it.

What order should you administer an IVP through a non-tunneled central venous catheter?

1. Cleanse access port 2. Connect 10 mL normal saline to access port 3. Gently aspirate for blood 4. Flush saline using push-pause method 5. Administer med 6. Flush with normal saline, then with heparin heparin is usually given to maintain catheter patency for a longer period of time to prevent thrombus formation.

What are the 6 rights of drug administration?

1. Right Patient 2. Right Drug 3. Right Dose 4. Right Route 5. Right Time 6. Right Documentation Mneumonic: Patients Do Drugs Round The Day

What are the 5 rights of delegation?

1. Right task- can it be delegated 2. Right Circumstance- Should it be delegated 3. Right person- can this person do the task 4. Right direction/ communication- is the task being conveyed in a clear manner 5. Right supervision- is the task being followed up on once complete.

If a patient was given REGULAR insulin at 8, what time is the patient at risk for hypoglycemia?

11 Regular insulin peaks after 2-3 hours of administration.

What kind of drugs should you give to a pediatric patient experiencing contact dermatitis? (contact eczema triggered by an allergic reaction)

Diphenhydramine Topical hydrocortisone cream Cyclosporine (reduce inflammation) Tacrolimus

Total hip replacement displacement prevention

Do not cross affected leg over the other leg Do not bend at waist more than 90 degrees Do not turn affected leg inward while lying in bed When sleeping, put pillow between legs

What can cause the development of right sided heart failure?

High blood pressure in the lungs. Higher pressure in the pulmonary circuit from such things as emphysema, the pulmonary pressure will excess the systemic pressure, The result is back flow to the right side of the hear and resulting right sided heart failure.

Early signs of bowel obstruction

High-pitched bowel sounds are indicative of an early bowel obstruction and worsens as it develops.

Patient reports, "the FBI has been watching my house and are going to raid it and arrest me" the nurse best response:

I believe your thoughts are disturbing you. Do not argue with patient or agree with them. Do not ask into the delusion cause it will encourage them to think that it is true.

What kind of edema (CHF) when palpated the nurse notes rebounds in 10-20 seconds. Use 1+ to 4+ scale

3+ 1+ edema is where there is slight indentation upon pressure but does not remain pitted. 2+ edema is bottomless pit, but it rebounds within seconds. 4+ edema is a bottles pit that takes more significant than 30 seconds to rebound.

What is the best indication of a positive Mantoux tuberculin skin test?

A central area of induration of 15 mm surrounded by erythema.

Patient (child) admitted with possible rheumatic fever. What assessment data would be most important for the nurse to obtain from the parent?

History of pharyngitis approx 4 weeks ago. It is an upper respiratory infection. Rheumatic fever is the result of untreated/ improperly treated group A beta hemolytic strep infection. In this question they're asking this question concerning rheumatic fever for a reason. Pick a question that correlates to this stem.

Who has the highest rate of developing a latex allergy?

Hospital housekeepers Professionals who routinely wear latex gloves, such as housekeepers, nurses or hairdressers are at a higher risk of developing a latex allergy than other populations. Reoccuring exposure.

What is gynecomastia and what is its cause?

Hypertrophy of ductal elements in men during puberty and later in life; it is caused by hormonal fluctuations, disease processes and medications. Testosterone deficiency.

Albumin and pre-albumin levels and what happens when they're too low?

Albumin 3.5-5.5 (Kind of like potassium) Pre-albumin 15-35 Low serum albumin results in loss of muscle mass (hypoalbuminemia)

What to do with patients with OCD? with frequent hand rituals

Allow time for rituals Provide positive reinforcements Create a regular schedule for taking client to bathroom Patient does not need a flexible but a structured schedule.

What is impetigo? What kind of precautions?

An acute, contagious superficial skin infection of the skin. "school sores" Contact and standard precautions

When taking SSRIs, what kind of questions should you asking the patient?

Ask about any adverse reactions. Patient could be experiencing serotonin syndrome (everything go up) Such as: muscle jerking (myoclonus), mental confusion, shaking, chills, high body temperature.

Priority action upon ingested unknown poison:

Assess patient Ensure no further exposure to poison Identify the specific type Administer antidote

What should the nurse do after the patient has been using contrast media via the femoral approach?

Assessment of kidney function tests to check if they're have been damaged during the trial. Hydration fluids are needs to aid in the excretion of the contrast media.

What is autonomic dysreflexia and what interventions should the nurse initiate?

Autonomic dysreflexia is a syndrome in which there is a sudden onset of excessively high blood pressure. It is more common in people with spinal cord injuries that involve the thoracic nerves of the spine or above (T6 or above). Assess bladder and bowel for distention Examine skin for pressure areas Eliminate drafts Remove triggering stimulus Administer hydralazine if BP does not return to normal.

What medication is used for mothers going through preterm labor and is used to stimulate maturation in baby's lungs?

Betamethasone

What type of precaution for hemophilia?

Bleeding precautions

How long can you administer blood for?

Blood be administered within the 4 hour time frame due to risk of hemolysis and bacterial invasion. If not completed, send back to the lab to be discarded. Must be given within 30 min after pickup.

The most serious adverse effect of tricyclic antidepressant (TCS) overdose is?

Cardiac arrhythmias

Nurse providing information regarding suicide at a high school assembly... what should the nurse include?

Do not keep secrets Express concerns for a person expressing thoughts about suicide Inform group of suicide intervention sources Do not leave a suicidal person alone

What can dopamine do to blood pressure?

Dopamine is a vasoconstrictor, this medication can cause high blood pressure. Should discontinue if nurse notice a change in blood pressure

What intervention do the nurse implement first when client have an unknown infection?

Draw blood culture/ culture specimen before any antibiotics/wound care/ meds/topicals

Psych patient says "everyone here hates me," nurses best response:

I cant speak for other but I don't hate you. Here the nurse is speaking for herself. Do not argue with what patient are saying and is nontherapeutic.

What s/s would prompt the nurse to discontinue nitroglycerin?

Cool and clammy skin. Decreased cardiac output meaning too much vasodilation.

What kind of advice should you share with a first trimester mother complaining of nausea?

Eat dry crackers before getting out of bed and drink small sips of water throughout the day instead of large amounts with meals. Do not brush teeth immediately after eating to avoid smells and tasted that trigger nausea.

Who has the highest rate of suicide?

Elderly In particular: -White elderly males > 75 yrs old -Widowed, living alone -Asian elderly females (highest among females) Ask patient "have you had thoughts of harming yourself?

13 year old in the hospital for repair of a spinal curvature. The adolescent is hospitalized for approx. 2 weeks. What intervention will be most helpful during hospital stay?

Encourage the patient to bring homework assignment to the hospital. Adolescent need to establish their identity, which includes developing a mature sense of responsibility and independence. Providing them schoolwork will keep him connected to his peer group and give him a sense of accomplishment. While peers interaction is important, the nurse can not expect the client's peers to frequently come and visit since they have school in the day.

Patient with major depression would get ECT done. Patient as "how many of these treatments do you think I will need?" Your best response:

Everyone is responds to treatment differently, but may require 6-12 or even 20 treatments. Nurse can answer general questions.

Health history data that shows increased risk for developing cancer:

Family history Alcohol consumption Tabaco use Human papillomavirus (warts in various parts of the body and most common STI-depends on the strain)

What is asbestosis?

Filling and inflammation of lung spaces with asbestos fibers. These fibers move into the alveolar space and cause fibrosis, leading to increased production in secretions impairing gas exchange.

What is priority for sickle cell crisis?

Fluids! Think HOP Hydration Oxygen Pain management

phenytoin is for? and how long should you push it?

For seizures 2 minutes (should not exceed 50mg/min in peds but 100 mg can be safely delivers over a period of 2 min)

3 year old is being prepared for a incision and drainage of large left leg abscess. What kind of anesthesia will be administered?

General anesthesia- large abscess will need significant time for incision and drainage. Children who are not mature enough to cooperate adequately during such surgical procedures requires general anesthesia because this minimizes fears of intrusive or mutilating procedures.

What is celecoxib? What education should be given?

Given to relieve pain/tenderness/swelling/stiffness caused by arthritis. DO NOT take with NSAIDS such as Ibuprofen GI complaints and headache are most common SE Notify HCP of black stools Provides relief of pain and swelling so you can perform normal ADL

What should patient with celiac disease avoid?

Gluten BROW- Barley, Rye, Oats, Wheat

Patient is closely monitored for the development of renal failure. Which assessment finding would warrant immediate reporting?

Gradual increase of BUN (10-20) levels. Gradual accumulation of nitrogenous waste results in elevated BUN and serum creatinine.

What color canister is carbon dioxide?

Grey

What is a hemangioma?

Harmless tumors of blood vessels that occur within first year of life. Can commonly appear on the face, scalp, chest and back. Bright red appearance that are often referred to ask "strawberry nevi." They blanch with pressure, which can help differentiate these lesions from port-wine stains.

suspected anthrax ask:

Have you recently worked with farm animals or any animal skin product?

What assessment should be notified to the HCP when beta-blockers are ordered?

Heart rate lower than 60 bpm HR lower than 60 should not be given beta-blockers since it does lower it even more.

Post thyroidectomy- require further investigation if patients says:

I have a tingling feelings of my finger" After this procedure the nurse should worry about the possibility of some of the parathyroid being accidently removed with resulting hypoparathyroidism (hypocalcemia). S/S numbness/ tingling/ burning feeling.

What does radiation and chemotherapy do to wound healing?

Increase and delay wound healing time

Schizophrenia with unkept appearance and needs to attend personal hygiene. What statement by nurse is most therapeutic?

It is time to take a shower. Patient with schizo have a hard time making decisions . Nurse needs to be direct clear and concise

What meds should nurse administer to patient suspected with an acute MI?

MONA Morphine O2 Nitroglycerin Aspirin

Liver disease interventions when patients physical assessment includes jaundice sclera, abdominal distention, swelling in legs and ankles, bruises in various stages of healing:

Measure abd Monitor I&Os Obtain daily weight Place on fall precautions

How do you determine the correct size for oropharyngeal airway for a client?

Measure from the earlobe to the corner of the mouth

What is the best way to collect urine specimen?

Midstream

Client in the psych ward states that he is going to kill his wife when he sees her. What is the nurse's next action?

Notify the client's psychiatrist of the comments. So that they can discuss in private therapy session. Do not explore the clients feelings about his wife, it could increase the client's ager toward her.

What is Omphacele and what interventions should the nurse apply?

Omphacele is a birth defect pf the abdominal wall. Baby's organs are covered in a thin, nearly transparent sac that is protruding from the belly. Nurse should keep moist by covering the sac with sterile gauze soaked in saline and baby should be placed under a radiant warmer for thermoregulation.

What type of pain below is accurately paired with one of its subjective sensory descriptors and one its is subject affective, emotional descriptors.

Pain: Drilling and Exhausting

Hyperventilation will cause what kind of acid base imbalance?

Respiratory alkalosis since you blowing out an excessive amount of acidic CO2, you are left with an alkalosis state.

What does a history of rheumatic fever mean in a pregnant client and what does it intel?

Rheumatic fever (disease that can affect heart, joints, lungs, brain and skin) can cause the formation of valvular lesions (damaged heart valve (e.g. mitral and tricuspid, aortic and pulmonary valve), which can lead to cardiac stress during pregnancy. Rheumatic fever can develop if strep throat and scarlet fever infections are not treated properly with antibiotics in order to prevent rheumatic fever.

What should the nurse suspect when patient states that he went hiking recently and showing up with macular rashes on his palms, wrist and soles of feet also complaining of fever, chills and headache lasting 2 days?

Rocky mountain Spotted Fever: will experience chills, fever, headache, spots, and macular rashes. Occurs due to Rickettsia bacteria that can be transmitted to humans via the Ixodid TICK. Needs to be diagnosed early or could be fatal!

When is the safest period for a pregnant lady to get dental extractions done?

Second trimester. No need to delay dental removal. Delaying could be harmful for mother and baby.

Patient has generalized urticaria. What type of precaution should the nurse apply?

Standard. Client is experiencing an allergic reaction. No isolation needed.

total laryngectomy

Surgical removal of the entire larynx- cannot speak/whisper cause trachea is closed off and air can no longer move air through the nasopharynx so client will have a hard time smelling. Educate client about having smoke detectors installed at home.

Evidence based practice best reliable source:

Systemic review and meta-analysis studies Case studies & Qualitive studies are not EBP may also involve bias from the the authors making them unreliable.

What does it mean when Asian look down at the floor while you are giving instructions?

The classified behavior is ATTENTIVENESS and respect for the nurse. Asians can consider eye contact rude and offensive.

What kind of birth defect diagnosis do infants with atrioventricular canal?

Trisomy 21, down syndrome is commonly associated with an atrioventricular canal. A hole in the wall separating the heart chamber and problems with the heart valves.

MAOIs (monoamine oxidase inhibitors): AVOID what kind of food?

Tyramine: Eating food high in tyramine whole on MAOI's is dangerously high level of tyramine in the body. This can lead serious rise in blood pressure. Foods such as: aged cheese. cured meats, smoked or process meats, liver, pickled , sauces, soybeans, dried or overripe fruits. alcohol beverages (yeast), and caffeine such as tea/coffee.

Why should you prioritize a pregnant women with a blister-like rash on the face with possible varicella rather than a person with: pertussis exposure of TB MRSA infected wound

Varicella is airborne. A blister on the face is a clear sign that it is still active. Airborne has a higher risk of transmission. Needs isolation right away. Pertussis is droplet. MRSA is contact isolation. Patient exposed to TB has no symptoms of active TB. Latent TB is not infectious itself.

The best indicator of ACTUAL fluid deficit:

WEIGHT! I&O Admission and current. It's an ACTUAL objective data.

Early signs of ICP

change in LOC Restlessness Confusion Slow Speech Delay in response Pupillary changes Impaired ocular movement Weakness one extremity or one side HA (constant, increases intensity)

What is hyperalimentation?

intravenous nutrition (parenteral) given through a special IV line

signs of hypoglycemia

sweating , trembling, tachycardia (cool and clammy you get candy)

What is clang association?

meaningless rhyming of words

What is hypoplastic left heart syndrome?

underdevelopment of the entire left side of the heart, mitral valve is small, left ventricle is small, aortic valve atresia usually present, descending aorta small, usually coarcation of aorta or interruption of the aortic arch

Behaviors with major depression

withdrawn, sitting in room with lights out and drapes closed, unkept appearance and severe insomnia but also sleeping too much is a sign of MD.