Nclex + Nclex Booklet+ Meds. IN

Support diagnosis of HIV 1. Rash on trunk with non-painful mucosa ulcer sore, fever 2. fatigue, harry "l. . . ", diarrhea, fever 3. swollen lymph

swollen lymph, diarrhea, fever, night sweats, dry cough, rash, cold sores, tingling and weakness, irritating mentral.

abdominal distention? 1. legs straight and elevated? 2.

upright position

Scabies 1. Wash cloth in cold water. 2.

•If patient is hospitalized, practice good handwashing technique, or use gloves while performing nursing procedure. apply cream from neck down. avoid moisture.

0-18 trust vs mistrust 2-3 autonomy vs shame & doubt 3-5 initiative vs guilt 6-12 industry vs inferiority 12-18 identity vs role confusion 19-40 intimacy vs isolation 40-65 generativity vs stagnation 65+ ego intregrity vs despair

...

4,500-10,000 normal WBC value. 1,500-7,500 Neutriphil lvl

...

Angry patient points figure at other patient 1. "ask other patient how it makes them feel." 2. "Calmly tell patient not to and go to room to control anger." 3. Call paitent out.

...

Assess client, check doc, check nurse, Check to ascertain if nay discrepancy had been documented with accompanying reason/s last.

...

Best breathing position for copd? 1. 45% 2.

...

Flumazenil (Romazicon) Naloxone hydrochloride (Narcan) Doxacuriun (Nuromax) Remifentanil (Ultiva)

...

Hypothermia and hyperthermia are both common in surgery. Unless body is cooled. Use Dantrolene for skeletal muscle relaxant.

...

Near by bus accident. Which may need further investigation when a charge nurse says, . . . 1. you will be performing out of your normal scope of practice. 2. You may need to put yourself and risk the safety of your life to save others.

...

Postanesthesia monitor temp every 15mins.

...

Epiglottitis 1. Do not give water? 2. 3.

... life threating

The nurse assesses vital signs on a client who has had epidural anesthesia. For which of the following should the nurse assess next? 1. Bladder distention. 2.Heache. 3. Postoperative pain. 4. Ability to move the legs.

1. Bladder distention. The last area to regain sensation is the perineal area, and the nurse should check the client for a distended bladder. The client has received a large volume of IV fluid since the epicural. All other assessments should be checked after bladder.

When an epidural catheter is used for postoperative pain management, the nurse should: 1. assess but not disturb the epidural dressing. 2.change the epodiral dressing daily 3. change the epidural dressing daily only if it is wet. 4. use strict aseptic technique when handling the epidural catheter.

1. assess but not disturb the epidural dressing. reason: The nurse should assess but not disturb the epidural dressing b/c the catheter can be easily dislodged and organism can easily be transmitted into the cns. the nurse should not have to change the dressing at all if a waterproof dressing is applied over the site. even with strict aseptic technique, a drain into a sterile cavity is a direct route for transmission of organisms and place a client at increased risk of infection.

Giving advice to mother of a 5 month old infant. 1. serve fruits/veg together 2. don't serive whole milk till after 1 year 3. Serve rice cereal 4.

1. kinda true 2. typicalls no whole milk till 9 months- 12 months just to be safe. 3. about 4 months rice cereal is ok.

The nurse is to administer flumazenil (Mazicon) I.V. for reversal of sedation. Which of the following interventions should be included in the care plan? (S all that applies). 1. Administer the med as a 2-mg bolus. 2.Given the medication undiluted in incremental doses. 3.Be alert for shivering and hypotension. 4.Use only a free-slowing I.V. line in a large vein. 5.Monitor the client's level of consciousness.

2,3,4,5.

Avoid wrong-site surgery by... 1. Ask the surgeon to preoperatively to mark with a permanent marker the correct knee. 2. Verbally ask the client to state his name, surgical site, and procedure. 3. Verify the correct client with the correct operative site by medical record and radiographic diagnostic reports. 4. call a "time-out" in the operating room to have the surgeon verify the correct knee before making the incision. 5. show the client an anatomic model of the surgical site

2,3,4. reason: client should mark the operative site in the preoperative period not the surgeon. show client the anatomical model will assist the client in understanding the location of the surgery but it will not prevent anyone from identifying the wrong site on the client.

A 250 lb male client recovering from general anesthesia has the following assessment findings:150bpm, 90/50 mm Hg, resp. rate, 28 breath/min, tympanic temperature, 99.8 F (37.7C) and rigid muscles. The nurse determines that the client is. 1. Exhibiting the effects of excessive blood loss experienced in the operating room and increases the rate of his IV infusion. 2. In the early stages of malignant hyperthermia and obtains emergency med. and notifies the anesthesiologist.

2. In the early stages of malignant hyperthermia and obtains emergency med. and notifies the anesthesiologist. Reason: 150 bpm or greater and muscle rigidity are early signs of hyperthermia. Larger body frames are at risk. Late signs include rapid increase in temp.

A client has had a nasogatric tube connected to low intermitted suction. The client is at risk for which of the following complications? 1. Confusion. 2. Muscle cramping. 3. Edema. 4. Tremors.

2. Muscle cramping. Reason.

After surgery. a client was treated for postoperative nausea and vomiting and now is experiencing hypotension and tachycardia. Which of the following medications would be most likely associated with these findings? 1. ondansetron hydrochloride (Zofran). 2. droperidol (inapsine). 3. prochlorperazine (Compazine). 4. promethazine (phenergam).

2. droperidol (inapsine). reason: hypotension and tachycardia are common adverse effects of droperidol and should be monitored closely by nurse. hypotensiona nd tachy are not common adverse effects of the other meds.

How often should the postoperative client's temperature be assessed during the first 24 hours after surgery? 1. q 2 hr 2. q 4 hr 3. q 6 hr 4. q 8 hr

2. q 4 hr

The nurse is teaching a client who has had a laparoscopic cholecystectomy about postoperative pain management. Which has deficient knowledge? 1. My pain is related to the gas used to distend my abdominal cavity. 2. My diet should include eating bland foods until the gas clears up 3. "My pain is related to the large incision and manipulation." 4. My pain should be relieved by walking to eliminate the gas.

3. "My pain is related to the large incision and manipulation."

The nurse should monitor the surgical client closely for which clinical manifestation with the administration of naloxone (Narcan)? 1. Dizziness. 2. Biliary colic. 3. Bleeding. 4. Urine retention.

3. Bleeding., careful of b/p issues

After the nurse has administered droperidol (Inapsine). Care is taken to move the client slowly based on the knowledge of droperidol's effect on the: 1. Central nervous system. 2. Resp. System 3. Caridovascular system 4. Psychoneurologic system.

3. Caridovascular system.Produces hypo but does not effect other system. Causes tachy and othostaic hypo. client should move slowly.

The nurse is planning to teach incisional care to a client before d/c. Which Intervention should be included? 1. Do nto touch your incision before our next appointment. 2. Clean your incision three times a day with hydrogen peroxide and water. 3. Do not be concerned about uneven lumps under the suture line. 4. If the staples don't come out by themselves. The surgeon will removed it by the next appointment.

3. Do not be concerned about uneven lumps under the suture line. Reason: Normal due to collagen is under the incision line because new tissue at different rate. Eventually it will smooth out. Do not use hydrogen peroxide may dry out skin.

The nurse is caring for a client who is using a portable wound suction unit. 6 hours following surgery the drainage is full. Nurse should? 1. Remove the drain from the incision. 2. Notify the surgeon. 3. Empty drainage. 4. Record the amount in the unit as output on the client's chart.

3. Empty drainage. Reason: surgeon will remove drainage. It is normal for drainage to be full after 6-8 hours and should be emptied. Emptied and measured but not jus measured. Must empty.

A client with impaired cardiac functioning is at risk during anesthesia induction with thiopental sodium ( sodium Pentothal)because this drug causes: 1. Bradycardia 2. Complete muscle relaxation 3. Hypotension 4. Tachypnea

3. Hypotension. short acting barbiturate. maybe a problem for people with impaired cardiac issues.

Which explanation would be most appropriate for a child when teaching him about general anesthesia induction? 1. You will be given an injection before you go to surgery to make you sleep. 2. You will breathe in oxygen through a facial mask and receive IV med to make you sleepy. 3. You will receive IV med to make you sleepy. 4. You will breathe in med through a facial mask to make you sleepy.

4. You will breathe in med through a facial mask to make you sleepy. For a child both is not given. IV not for starting off.

The client tells the preoperative nurse that she cannot hear without her hearing aid and asks to wear it to surgery and recovery. What is the nurse's best response? 1. Explain to the client that it is policy not to take personal items to surgery because they may be lost or broken. 2. Tell the client that she will bring the hearing aid to the post anesthesia care unit so that she can have it as soon as she wakes up. 3.Explain to the client that she will have a premedication that will make her sleepy before she goes to surgery nd wont need to hear, 4.Call the surgery unit to explain the client's concern and ask if she can wear her hearing aid to surgery.

ANS: 4. Call the surgery unit to explain the client's concern and ask if she can wear her hearing aid to surgery. Previously I choose 2.

The nurse is reviewing the chart of a 55 year old male client who is scheduled for lumbar laminectomy, The nurse should report which of the following to the surgeon? 1. Pimple on the lower back. 2. Abnormal electrocardiogram. 3. Hearing aid. 4. Allergy to iodine When completing the preoperative checklist on the nursing unit. the nurse discovers an allergy that the client has not reported. What should the nurse do first? 1. Administer the prescribed pre-anesthetic med. 2. Not this new allergy prominently at the front of the chart. 3. Contact the scrub nurse in the operating room. 4. Inform the nurse anesthetist.

Ans: 1. infection risk 2. notify anethesist 3. 4. surgical team. Ans: 4. Inform the nurse anesthetist. Reason: The nurse anesthetist admin,s the agent and monitor the client;s phycial status throughout the sugery; the nurse anesthetist must have knowledge of all known allergies for the safety.

What therapeutic outcome does the nurse expect for a client who has received a premedication of glycopyrrolate (Robinul)? 1. Increased heart rate. 2. Increased respiratory rate. 3. Decreased secretions. 4. Decreased amnesia.

Glycopy is an anticholinergic gicen for its ability to reduce oral and resp. secretions before general anesthesia. Increased heart rate and resp rate with be adverse effects of the drug. Amnesia should not be an effect of the drug.

Myasthenia gravis

Intermittent immune atk triggered by stress, idiopathic, etc . . . causes failure to contract and auto-atk. S/S muscle weakness, droppy eyes ("gravity bringing down eyes" ,main sign). ONLY ALS, nerves YOU control have an effect. Diagnosis: tenselon test. inject cholinergic agents to produce siliva etc, muscle tone, vagus nerves to slow down heart beat. Tx: thymus-ectomy 2/3 effective.

Mother with fetal decal during contraction only. 1. normal? 2. cord prolapse. 3. call physician immediately. 4. head compression

Means its an early deceleration? Late deceleration is low FHR even after contraction. 2. cord prolapse is variable decel. 4. head compression is early decal.

client with infection wound @ homecare, teaching correct when. 1. client says to place wound dressing in sealed bag before disposing in regular trash can. 2.

Must be properly separated from regular waste.

Predisone

Notify anesthesis. immunosuppressant drug. suppresses corticosteroid in times of stress.

Which pediatric surgery client should not play with balloon? 1. A child having her 15th laser surgery for a meningioma.

Repeated exposure increases sensitivity to latex.

cystic fibrosis

Salty sweat, pancreatitis dx: young, blood sample tx: heavy vitamins, avoid smoke, high fluids, exercise

Which of the following items of documentation is not required for the nurse to have on the chart before client is transported? operative consent, hus and physical information, laboratory test, anesthesia note.

anesthesia note. Anesthesia notes are after (postoperative).

Surgical signs of client rubbing her eyes and wipe away nasal drainage is very early signs of allergy.

immediate action of stopping infusion or removing catheter (latex)

5 months old 1. infant should have head lag 2. leg lag 3.

infant head lag

An 80 year old clien has spinal anesthesia for a transurethral resection of the prostate and receieved 4,000 mL of room temperature isotonic bladder irrigation. He now has continuous irrigation through a three-way indwelling urinary catheter. Which postoperative nursing intervention is most important to include in his plan of care? 1. Empty the catheter drainage bag. 2. Cover the client with warm blankets. 3. Han new bags of irrigation. 4. Turn client.

2. Cover the client with warm blankets. Reason: Elderly (80! will freeze), Spinal anesthesia (causes vasodilation= Heat loss). bladder irrigation all contributes to hypo.

The nurse teaches a client who had cystoscopy about the urge to void when the procedure is over. What other teaching should be included? 1. Ignore the urge to void. 2. Force fluids. 3. Ask for the bedpan. 4. Ring for assistance to the bathroom.

2. Force fluids. Encourage to make fluid dilute. Scope into bladder. mucosal membrane is irritated and the client feels the need to void even though the bladder may not be full. Client should never avoid urge to void.

Preadmission nurse usually responsible for discharge planning as well.

...

delegate to nursing assistant. 1. collect drainage amount. 2. clean wound area.

...

naloxone (Narcan) to reverse the resp. depression. Monitor resp. freq. for 4 to 6 hrs. may need for repeated dose.

...

prevent nosocomial infection. 1. remove gloves after leaving room. 2. wash hands with "chemical"

...

peritoneal? something select all that applies 1. sitz bath. 2.non irritation cream. 3.

... 1,

When physician ask a patient who has been 8 hours into sedation to sign inform consent which is in violation. 1. unintentional tort 2. maleficent 3. justice 4. fidelity

...justice

For which of the following preoperative clients should the nurse assess the glucose level? Select all that apply. 1. A client with a diabetes mellitus controlled by diet. 2. A client with a high stress response to surgery. 3. A client receving corticosteroids for the past 3 months. 4. A client with a family history of diabetes receving dex. 5% in lactated ringer's solution (D5LR) I.V. fluids. 5. A client whi consumes a high carbohydrate diet.

1. A client with a diabetes mellitus controlled by diet. 2. A client with a high stress response to surgery. 3. A client receving corticosteroids for the past 3 months. Not 4. b/c hx: does not make the client actually have diabetes.

Atropine sulfate (Atropine) is contraindicated in all BUT which one of the following clients? 1. A client with diabetes. 2. A client with glaucoma. 3. A client with urine retention. 4. A client with bowel obstruction.

1. A client with diabetes. Just need to read question carefully.

A client will receive I.V. midazolam hydrochloride (Versed) during surgery. Which of the following should the nurse determine as a therapeutic effect? The nurse should also encourage? Deep and slow breathing. 1. Amnesia. Correctly picked. 2. Nausea. 3. Mild agitation. 4. Blurred vision.

1. Amnesia. RN should also encourage slow and deep breathing. midazolam is also a respiratory depressant.

A 15 year old client needs life saving emergency surgery but his relatives live an hour away from the hospital and cannot sign the consent form. What is the nurse's best response? 1. Send the client to surgery without the consent? 2. Call the family for a consent over the telephone and have another nurse listen as a witness? 3. No action is necessary in this case because consent is not needed. 4. Have the family sign the consent form as soon as they arrive.

2. Call the family for a consent over the telephone and have another nurse listen as a witness? Reason: If not family available and life threatening, no consent for need.

Metoclopramide (Reglan is ordered as a premedication for a client about to undergo a gastroduodenoscopy. The nurse expects which of the following as the primary therapeutic effect? 1. Inhibit gastric emptying. 2. Increase gastric pH. 3. Reduced anxiety. 4. Inhibited respiratory secretions.

1. Inhibit gastric emptying. Metoclopramide is an antiemetic.

When a client cannot read or write but is of sound mind and needs to fill out consent form/ 1. Have the clients next of kin sign. 2. have client put an "X" on the signature line. 3. havea court appoint a guardian for the client 4. have a hospital quality mamangement coordinator sign for the client.

2. have client put an "X" on the signature line. reason: guardian will not be appointed for a sound mind client. kin does not sign for the client neither management coordinator.

The nurse anticipates that a client who has received propofol (Diprivan) as the induction and maintenance agent for general anesthesia will most likely experience: 1. Minimal nausea and vomiting. 2. Hypotension. 3. Slow induction of anesthesia. 4. Small tremors of the skeletal muscle.

1. Minimal nausea and vomiting. A nonbarbiturate anesthetic direct antiemetic action.

A nurse is assessing a surgical client's blood pressure 8 hrs after surgery. The client's blood pressure before surgery was 120/80 mm Hg and on admission to the postsurgical nursing unit, it was 110/80 mm Hg. The client's blood pressure is now 90/70 mm Hg. What should the nurse do first? 1. Notify the health care provider. 2. Elevate the head of the bed. 3. Administer pain med. 4. Check the intake and output record.

1. Notify the health care provider.

A client has been positioned in the lithotomy position under general anesthesia for a pelvic procedure. In which anatomic area may the client expect to experience postoperative discomfort? 1. Shoulders. 2. Thighs. 3. Legs. 4. Feet.

1. Shoulders. Reason: The client who has been positioned under general anesthesia may experience discomfort in the shoulders postoperatively because the client is placed in the trendlenburg position to expose the perineal area. The client's weight is then shifted towards the should and the client experiences muscle sorness postoperatively.

Mother in 3rd stage of labor. 1. tell her to relax between contraction. 2. tell her not to push till full dilation. 3.

2. tell her not to push till full dilation.=2nd 1. tell her to relax between contraction.= first stage 3rd stage complete delivery.

The nurse is teaching the client about deep breathing technique. Which of the following client statements indicates the need for additional education? 1. will use my incentive spirometer every hr while im awake. 2. I should place my hands lightly over my lower ribs and upper abdomen 3. I should get into a comfortable position before doing my breathing exercise 4. I should take four deep breaths and then cough deeply from the lungs

3. I should get into a comfortable position before doing my breathing exercise. Reason: must maintain upright position.

20 weeks patient gain 12 lbs. response should be? 1. 1/4 of planned weight. 2. consume more calories. 3. Ideal weight. 3. You consumed too much.

3. Ideal weight.

The nurse is preparing a preoperative teaching plan for a client who is undergoing a bilateral breast reduction. Which aspect of the plan is the priority? 1. Reduction of risk potential. 2. Physiologic adaptation. 3. Psychosocial integrity. 4. Health promotion and maintenance.

3. Psychosocial integrity.

The initial post operative assessment is completed on a client who had an arthroscopy of the knee. Assessment of which of the following parameters is not necessary every 15 minutes during the first postoperative hour? 1. vital signs including pulse oximeter. 2. Pain rating of the operative site. 3. Urine output. 4. Neurovascular check distal to the operative site.

3. Urine output. Reason: all out vital signed checked for compartment syndrome. patient does not have a urinary catheter. Urine is measured but not check q 15mins.