NCLEX qsn from FB

Let us look at AV Blocks 1. The nurse in cardiac unit noticed abnormal wave form on cardiac monitor and concluded it is 2nd degree AV block because she knows that the hallmark of 2nd degree type1 AV block is A. Prolonged ST segment B. Elongation of T waves C. Cyclic lengthening of PR intervals D. Abnormally long PR interval.

Answer C

The newborn infant of an HIV-positive mother is admitted to the nursery. The nurse should include which of the following in the plan of care? 1. Standard precautions. 2. Testing for HIV. 3. Transfer to an acute care nursery facility. 4. Place the infant in isolation.

(1) CORRECT—provides immediate protective care for the staff members (2) might be employed, safety is the priority (3) might be employed, is not a priority (4) isolation not required; infant may be in normal nursery

The nurse cares for clients in the pediatric clinic. A mother reports that her infant's smile is "crooked". The nurse should assess which of the following cranial nerves? 1. III. 2. V. 3. VII. 4. XI.

(3) CORRECT—facial; provides motor activity to the facial muscles (1) oculomotor; provides innervation for extraocular movement (2) trigeminal; provides sensation to facial muscles (4) spinal accessory; provides innervation to the trapezius and sternocleidomastoid muscles

The nurse provides care for a client receiving a heparin drip via an infusion pump. The health care provider prescribes warfarin 5 mg PO. Which action does the nurse take next? 1. Administers medication as prescribed. 2. Notifies the health care provider. 3. Checks the most recent partial thromboplastin time. 4. Assesses client for signs/symptoms of bleeding.

1) CORRECT - Warfarin interferes with the hepatic synthesis of vitamin K-dependent clotting factors. Oral anticoagulant therapy must be instituted 4 to 5 days before discontinuing the heparin therapy. 2) There is no reason to notify the health care provider because this is appropriate. 3) A partial thromboplastin time is used to monitor the effectiveness of heparin, not warfarin. The therapeutic level is 1.5 to 2 times the control. International normalized ratio is used to monitor warfarin. The therapeutic level is 2 to 3 times the control. 4) Warfarin takes 3 to 5 days to reach peak levels.

The nurse provides care for a client receiving a heparin drip via an infusion pump. The health care provider prescribes warfarin 5 mg PO. Which action does the nurse take next? 1. Administers medication as prescribed. 2. Notifies the health care provider. 3. Checks the most recent partial thromboplastin time. 4. Assesses client for signs/symptoms of bleeding.

1) CORRECT - Warfarin interferes with the hepatic synthesis of vitamin K-dependent clotting factors. Oral anticoagulant therapy must be instituted 4 to 5 days before discontinuing the heparin therapy. 2) There is no reason to notify the health care provider because this is appropriate. 3) A partial thromboplastin time is used to monitor the effectiveness of heparin, not warfarin. The therapeutic level is 1.5 to 2 times the control. International normalized ratio is used to monitor warfarin. The therapeutic level is 2 to 3 times the control. 4) Warfarin takes 3 to 5 days to reach peak levels.

The nurse provides care for a newborn who is prescribed phototherapy for hyperbilirubinemia. Which actions will the nurse implement when providing care to this client? (Select all that apply) 1. Remove the newborn's eye patches during feedings. 2. Place the newborn 15 cm (6 in) below the phototherapy lights. 3. Reposition the newborn every 4 hours. 4. Cover the newborn with light cotton clothing. 5. Cluster activities when caring for the newborn.

1) CORRECT — The nurse should place eye patches over the newborn's eyes to prevent retinal damage, but should remove them at least every 2 to 3 hours to assess the skin and to promote stimulation and bonding with parents during feedings. 5) CORRECT — When performing care for the newborn, the nurse should cluster care to ensure the newborn obtains maximum exposure to the lights. 2) INCORRECT - The newborn should be placed about 30 to 40 cm (12 to 16 in) below the bank of phototherapy lights to prevent injury to the skin. 3) INCORRECT - The nurse should reposition the newborn at least every 2 hours to provide stimulation, maximize skin exposure to the lights, and prevent skin breakdown. 4) INCORRECT - The nurse should dress the newborn only in a diaper to maximize skin exposure to the lights.

The nurse provides care for a newborn who is prescribed phototherapy for hyperbilirubinemia. Which actions will the nurse implement when providing care to this client? (Select all that apply.) 1. Remove the newborn's eye patches during feedings. 2. Place the newborn 15 cm (6 in) below the phototherapy lights. 3. Reposition the newborn every 4 hours. 4. Cover the newborn with light cotton clothing. 5. Cluster activities when caring for the newborn.

1) CORRECT — The nurse should place eye patches over the newborn's eyes to prevent retinal damage, but should remove them at least every 2 to 3 hours to assess the skin and to promote stimulation and bonding with parents during feedings. 5) CORRECT — When performing care for the newborn, the nurse should cluster care to ensure the newborn obtains maximum exposure to the lights. 2) INCORRECT - The newborn should be placed about 30 to 40 cm (12 to 16 in) below the bank of phototherapy lights to prevent injury to the skin. 3) INCORRECT - The nurse should reposition the newborn at least every 2 hours to provide stimulation, maximize skin exposure to the lights, and prevent skin breakdown. 4) INCORRECT - The nurse should dress the newborn only in a diaper to maximize skin exposure to the lights.

The nurse provides care for a client who had a positive urine pregnancy test. The client states the last normal menstrual period began on September 11, 2017 and ended on September 18, 2017. What is the client 's estimated date of delivery (EDD) according to the Naegele rule? 1. June 18, 2018. 2. June 25, 2018. 3. July 4, 2018. 4. July 17, 2018.

1) CORRECT — Using the Naegele rule, subtract 3 months from the date of the FIRST day of the last normal menstrual period (September 11 - 3 months = June 11th), add 7 days (June 11th + 7 days = June 18th), and then correct the year. In this situation, the correct EDD is June 18, 2018.

The nurse provides care for a client diagnosed with right-sided heart failure. The nurse expects which assessment findings? (Select all that apply.) 1. Dependent edema. 2. Distended jugular veins. 3. Urinating less frequently. 4. Third heart sound (S 3). 5. Intermittent weight gain. 6. Dry, nonproductive cough.

1) CORRECT— Right-sided heart failure is caused by failure of the right ventricle, which causes a backup of circulation. This results in dependent edema. 2) CORRECT— Venous jugular distention is caused by the increased venous pressure that occurs with right-sided heart failure. 5) CORRECT— Weight gain occurs due to fluid retention. Kidney perfusion is decreased by the weaker pumping of the heart, the kidneys react to the decreased perfusion by retaining sodium to increase fluid volume and pressure to increase perfusion. A weight gain of 2 lbs (0.91 kg) per day or 5 lbs (2.27 kg) in 1 week requires medication adjustments. 3) INCORRECT - Right-sided heart failure is accompanied by frequent urination, not less, especially at night. 4) INCORRECT - A third heart sound is found in left-sided heart failure, the result of a dilated left ventricle. A benign third heart sound is also sometimes heard in pregnancy, childhood, and in trained athletes. 6) INCORRECT - A dry cough is associated with initial left-sided heart failure. Right-sided heart failure is often the result of prolonged left-sided heart failure.

The nurse provides care for a client diagnosed with right-sided heart failure. The nurse expects which assessment findings? (Select all that apply.) 1. Dependent edema. 2. Distended jugular veins. 3. Urinating less frequently. 4. Third heart sound (S 3). 5. Intermittent weight gain. 6. Dry, nonproductive cough.

1) CORRECT— Right-sided heart failure is caused by failure of the right ventricle, which causes a backup of circulation. This results in dependent edema. 2) CORRECT— Venous jugular distention is caused by the increased venous pressure that occurs with right-sided heart failure. 5) CORRECT— Weight gain occurs due to fluid retention. Kidney perfusion is decreased by the weaker pumping of the heart, the kidneys react to the decreased perfusion by retaining sodium to increase fluid volume and pressure to increase perfusion. A weight gain of 2 lbs (0.91 kg) per day or 5 lbs (2.27 kg) in 1 week requires medication adjustments. 3) INCORRECT - Right-sided heart failure is accompanied by frequent urination, not less, especially at night. 4) INCORRECT - A third heart sound is found in left-sided heart failure, the result of a dilated left ventricle. A benign third heart sound is also sometimes heard in pregnancy, childhood, and in trained athletes. 6) INCORRECT - A dry cough is associated with initial left-sided heart failure. Right-sided heart failure is often the result of prolonged left-sided heart failure.

The nurse prepares a client for a skin biopsy. Which client statement does the nurse report to the health care provider? 1. "I have been taking aspirin for my aching joints." 2. "I applied lotion to my skin after my shower last night." 3. "I laid out in the sun yesterday." 4. "I had coffee and a sweet roll for breakfast this morning."

1)CORRECT - Aspirin can increase the risk for bleeding and should be reported. Taking a biopsy provides an opportunity for bleeding to occur. 2) Lotion from the previous evening will have been absorbed and does not affect the biopsy. The area to be biopsied will be cleansed. 3) While sunbathing is not a good health habit, it does not affect the biopsy. 4) A punch or shave biopsy is usually performed on the skin and does not require the client to be NPO. After the biopsy, the client should clean the site once a day with tap water or saline. The site is left open to the air after the first 24 hours.

The nurse receives report on the medical-surgical unit. Which client does the nurse see first? 1. A client 2 days after a total hip replacement and who slid out of bed when trying to stand. 2. A client with a history of cardiomyopathy and who aspirated cooked cereal at breakfast. 3. A client diagnosed with a right-sided stroke and who requires assistance going to the bathroom. 4. A client diagnosed with heart failure and who has been vomiting for 3 days.

2) CORRECT - The nurse needs to ensure the client has a patent airway. This client is at risk to develop pneumonia and needs close monitoring. 1) The nurse needs to assess whether dislocation of the prosthesis has occurred. However, airway problems take priority. 3) The nurse needs to ensure the client's safety and assistance may be delegated to an unlicensed assistive personnel. The client with an impaired airway takes priority. 4) Assess this client second. Vomiting may indicate digoxin toxicity. This is a circulatory problem and not a new one. The client with an impaired airway is the priority.

The nurse supervises care provided by an unlicensed assistive personnel (UAP). Which action by the UAP requires an intervention by the nurse?(Select all that apply) 1. The UAP applies nonsterile gloves to empty a client's urostomy bag. 2. The UAP applies elastic compression stockings to a client after the client returns to bed after breakfast. 3. The UAP assists a 418.8 lb (190 kg) client diagnosed with lower extremity weakness to the bathroom. 4. The UAP wears a gown and gloves when assisting a client just admitted with meningitis to change into a hospital gown. 5. The UAP documents morning vital signs and blood glucose levels obtained from a group of clients.

2) CORRECT — Compression stockings are placed after elevation of the limbs or when there is minimal dependent edema. The client who has been up for breakfast will have increased dependent edema. The nurse should remind the UAP to place compression stockings before the client gets up. 3) CORRECT — This client has lower extremity weakness and requires additional assistance in transfers to ensure the safety of the client and the UAP. The nurse should remind the UAP to ask for help prior to assisting this client to the bathroom. 4) CORRECT — The client diagnosed with meningitis is placed on droplet precautions. The nurse reminds the UAP to don a mask prior to entering the client's room. 1) INCORRECT — This is an appropriate action and is within the scope of practice for the UAP. Emptying a urostomy bag is a nonsterile procedure and does not require sterile gloves. Nonsterile gloves are necessary as the UAP may come into contact with bodily fluids (urine). 5) INCORRECT — This is an appropriate action and is within the scope of practice for the UAP.

During a well-child checkup, the nurse evaluates the reflexes of a client who is 6 months of age. Which finding is of concern to the nurse when observed? 1. Presence of a positive Babinski reflex. 2. Extrusion reflex when feeding. 3. Ability to grasp objects voluntarily. 4. Ability to roll from abdomen to back at will.

2) CORRECT — The extrusion reflex disappears between 3 and 4 months of age. An infant uses this movement of the tongue as a normal reflex when anything touches the lips. It helps with sucking from a breast or bottle. 1) INCORRECT — A positive Babinski reflex disappears at approximately 1 year of age. The nurse would expect to observe it at 6 months. 3) INCORRECT — Grasping objects is a normal occurrence at this age. 4) INCORRECT — Rolling from the abdomen to the back is a normal occurrence at this age.

During a well-child checkup, the nurse evaluates the reflexes of a client who is 6 months of age. Which finding is of concern to the nurse when observed? 1. Presence of a positive Babinski reflex. 2. Extrusion reflex when feeding. 3. Ability to grasp objects voluntarily. 4. Ability to roll from abdomen to back at will.

2) CORRECT — The extrusion reflex disappears between 3 and 4 months of age. An infant uses this movement of the tongue as a normal reflex when anything touches the lips. It helps with sucking from a breast or bottle. 1) INCORRECT — A positive Babinski reflex disappears at approximately 1 year of age. The nurse would expect to observe it at 6 months. 3) INCORRECT — Grasping objects is a normal occurrence at this age. 4) INCORRECT — Rolling from the abdomen to the back is a normal occurrence at this age.

A child in a new plaster walking cast has dusky, swollen toes. Which action by the nurse is most appropriate? 1. Get Doppler studies to check the pulse. 2. Notify the healthcare provider. 3. Determine if the cast is dry. 4. Check the client's vital signs.

2) CORRECT- Outcome priority and desired; diminished pulses indicates change in distal circulation. Any changes in pulse, color, sensation should be reported immediately to the healthcare provider. Therefore, this action is appropriate for the nurse to perform.

A nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead there are wavy lines. The QRS complexes measure 0.08 second, but they are irregular, with a rate of 120 beats a minute. The nurse interprets this rhythm as: 1). Sinus tachycardia 2). Atrial fibrillation 3). Ventricular tachycardia 4). Ventricular fibrillation

2) CORRECT: Atrial fibrillation is characterized by a loss of P waves; an undulating, wavy baseline; QRS duration that is often within normal limits; and an irregular ventricular rate, which can range from 60 to 100 beats per minute (when controlled with medications) to 100 to 160 beats per minute (when uncontrolled).

An LPN/LVN calls the health care facility charge nurse before coming to work. The LPN/LVN reports, "I have been diagnosed with strep throat and placed on antibiotics." Which response by the charge nurse is best? 1. "How long have you had the sore throat?" 2. "How long have you been on antibiotics?" 3. "Do you have an elevated temperature?" 4. "Do you have a health care provider's release to work?"

2)CORRECT - After 24 hours of antibiotic therapy, strep throat is no longer contagious and a health care worker can resume responsibilities. 1) The duration of the sore throat is not relevant to being able to work. 3) Fever is the body's reaction to disease as a defense mechanism. Being afebrile is often a condition for being able to work, but the duration of antibiotic therapy is the best indicator. 4) The LPN/LVN does not need the health care provider's release in the case of strep throat, unless there is a facility policy making it a requirement.

Which of the following nursing interventions are written correctly? SATA A. Apply continuous passive motion machine during the day. B. Perform neurovascular checks C. Elevate head of bead 30 degrees before meals. D. Change dressing once a shift.

Correct answer is C only! It is specific in what to do and when

The nurse in the pediatric clinic receives a phone call from the parent of a 3-year-old client. The parent reports the client has a sore throat, a temperature of 102°F (39°C), and suddenly begun drooling. Which suggestion does the nurse make first? 1. "Place a cold water vaporizer in your child's room." 2. "Take your child to the emergency department immediately." 3. "Look into your child's throat and tell me what you see." 4. "Offer your child oral fluids frequently."

2)CORRECT - These symptoms indicate acute epiglottitis, which can be life-threatening. Drooling occurs because of difficulty swallowing. The child may become apprehensive or anxious. The child should be transported to hospital sitting in an upright position to aid in breathing. 1) While this is an appropriate action if the child has croup, these symptoms suggest the child has progressed to epiglottitis and needs to be seen immediately. 3) Do NOT inspect the throat unless immediate intubation can be performed if needed. Touching the back of the throat may cause spasms cutting off the ability to breathe. 4) Immediate transport to the hospital is required in this emergency situation.

An adolescent client is in the emergency department. The nurse approaches the client to draw a blood sample. The client cries out, "I hate having my blood drawn. Go away!" Which response by the nurse is best? 1. "What's the matter? Are you afraid of what we are going to find?" 2. "What is it about having your blood drawn that upsets you?" 3. "Take a deep breath. It will be over before you know it." 4. "I'll be back in 15 minutes so we can discuss your concern."

2)CORRECT - This question is more open-ended. It relates to the client's verbal and nonverbal communication and responds to the client's feelings. 1) This is a yes-no question, and the nurse is making an assumption about the reason for the outburst. 3) A "don't worry" response is nontherapeutic and makes the client's concern seem trivial. 4) The nurse should not leave the client alone. Waiting 15 minutes will not change the situation.

An adolescent client is in the emergency department. The nurse approaches the client to draw a blood sample. The client cries out, "I hate having my blood drawn. Go away!" Which response by the nurse is best? 1. "What's the matter? Are you afraid of what we are going to find?" 2. "What is it about having your blood drawn that upsets you?" 3. "Take a deep breath. It will be over before you know it." 4. "I'll be back in 15 minutes so we can discuss your concern."

2)CORRECT - This question is more open-ended. It relates to the client's verbal and nonverbal communication and responds to the client's feelings. 1) This is a yes-no question, and the nurse is making an assumption about the reason for the outburst. 3) A "don't worry" response is nontherapeutic and makes the client's concern seem trivial. 4) The nurse should not leave the client alone. Waiting 15 minutes will not change the situation.

A mother has just brought her 4year old baby who was discharged home 8 months ago after being treated of Kawasaki disease for MMR vaccination. On enquiry, the mother informed the nurse that her baby had received IVIG therapy before discharge. What should the nurse do next? 1. Give the child 300mg of Paracetamol IM and administer the vaccine 2. Administer the vaccine in the deltoid muscle and monitor child for fever 3.Withhold vaccine and ask the woman to bring her child back after 3 months 4. Tell the woman to go home with her child because the child is already protected by the Kawasaki disease.

3 is correct. Live vaccines such as Varicella, MMR, etc. should be delayed 11 months after Intravenous immunoglobulin(IVIG) because this therapy may decrease the child's ability to produce the appropriate amount of antibodies to provide life long immunity.

The nurse plans assignments for the day after receiving report on the pediatric unit. Which client does the nurse see FIRST? 1. A client diagnosed with leukemia and reporting fatigue. 2. A client diagnosed with Wilms tumor and reporting thirst. 3. A client diagnosed with hemophilia and reporting joint pain. 4. A client diagnosed with gastroesophageal reflux and reporting abdominal pain.

3) CORRECT - Joint pain with hemophilia indicates bleeding and needs to be addressed as soon as possible. Treatment includes factor VIII, RICE (Rest, Ice, Compression, and Elevation). This client requires immediate attention and needs to be seen first. 1) Fatigue is expected because of the diagnosis and treatment with chemotherapy. It is necessary to balance rest and activity for this client. 2) This client does not require immediate attention. A Wilms tumor is a malignant neoplasm of the kidney and is the most common intra-abdominal tumor in children. 4) Gastroesophageal reflux is a backflow of gastric contents into the esophagus from the stomach resulting from relaxation of the lower esophageal sphincter. The abdominal pain requires investigation but is not the priority.

The nurse comes upon a vehicle accident. Which client does the nurse see first? 1. An infant who is strapped in a car seat and crying uncontrollably. 2. A child who is crying that the leg is broken. 3. A restless client with pale, cool, clammy skin, and a rigid abdomen with absent bowel sounds. 4. An alert, but mildly disoriented client with a scalp laceration with well-controlled bleeding.

3) CORRECT - This client likely has injuries to abdominal organs, resulting in hemorrhage and severe circulatory compromise. This client requires immediate evaluation. 1) There are no indications the infant is unstable or injured. 2) A broken leg is a concern, but the priority is the client who has indications of shock. 4) Although the client has mild circulatory compromise, the bleeding is well-controlled. This client requires further evaluation but does not take priority at this time.

The nurse comes upon a vehicle accident. Which client does the nurse see first? 1. An infant who is strapped in a car seat and crying uncontrollably. 2. A child who is crying that the leg is broken. 3. A restless client with pale, cool, clammy skin, and a rigid abdomen with absent bowel sounds. 4. An alert, but mildly disoriented client with a scalp laceration with well-controlled bleeding.

3) CORRECT - This client likely has injuries to abdominal organs, resulting in hemorrhage and severe circulatory compromise. This client requires immediate evaluation. 1) There are no indications the infant is unstable or injured. 2) A broken leg is a concern, but the priority is the client who has indications of shock. 4) Although the client has mild circulatory compromise, the bleeding is well-controlled. This client requires further evaluation but does not take priority at this time.

The nurse notes that a patient is positive for the hepatitis B surface antigen. Which questions should the nurse include in the patient's assessment to help determine the source of the infection? Select all that apply. 1. "Have you been anywhere where the water may have been contaminated?" 2. "Have you eaten any food in areas where the workers may not have had access to hand washing?" 3. "Have you had unprotected sex with anyone who has hepatitis B?" 4. "Have you eaten any raw shellfish lately?" 5. "Have you had a recent blood transfusion?" 6. "Do you share needles with anyone?"

3) CORRECT - hepatitis B is shed in the body fluid of infected individuals; a mode of transmission of hepatitis B is from unprotected sex with someone who is infected 5) CORRECT - hepatitis B is shed in the body fluid of infected individuals; a mode of transmission of hepatitis B is from blood transfusions 6) CORRECT - hepatitis B is shed in the body fluid of infected individuals; a mode of transmission of hepatitis B is needle sharing 1) hepatitis A is spread through the fecal-oral route by ingestion of fecal contaminants 2) hepatitis A is spread through the fecal-oral route by ingestion of fecal contaminants 4) refers to transmission hepatitis A

The nurse assesses a dark-skinned client for the presence of cyanosis. Which body area does the nurse use for the assessment? 1. Back of the hands. 2. Earlobes. 3. Palms of the hands. 4. Sacrum.

3) CORRECT — In a dark-skinned client with cyanosis, the palms of the hands will have a bluish tinge or be ashen gray, which is acrocyanosis. If experiencing central cyanosis, a bluish or gray tint to the mucous membranes and conjunctiva is expected.

The nurse finds a visitor slumped to the floor of a client's room during visiting hours at the hospital. Which action does the nurse take initially? 1. Start rescue breathing and chest compressions. 2. Call for help. 3. Shake the visitor and shout, "Are you all right?" 4. Listen for breath sounds.

3) CORRECT — The nurse should assess for unconsciousness. Then call for help. 1) INCORRECT — The nurse should first assess the visitor's level of consciousness and pulse prior to beginning CPR. 2) INCORRECT — The nurse should first assess the visitor's level of consciousness to determine the situation. 4) INCORRECT — The nurse should first assess for unconsciousness.

The nurse finds a school-age client having a tonic-clonic seizure. Which action will the nurse take first? 1. Call for help. 2. Place a padded tongue blade between the teeth. 3. Place a pillow under the head. 4. Straddle the legs and hold the arms.

3) CORRECT— The client needs to be protected from injury. Depending upon where the client is located, placing a pillow under the head would be essential. The nurse may also need to raise the bed side rails, pad the side rails, loosen clothing, and clear space around the client if the client is in the bed.

A client has a diagnosis of heart failure. It is most important for the nurse to clarify which prescription by the health care provider? 1. Furosemide 20 mg IV every 12 hours. 2. Sodium diet of 2 gram per day. 3. Normal saline at 125 mL/hour IV. 4. Oxygen at 2 L per nasal cannula.

3)CORRECT - Clients diagnosed with heart failure often have excess fluid volume. It is often necessary to restrict fluids, so this volume of IV fluids would only add to the fluid volume. The nurse should weigh the client daily and measure I and O. 1) This is an appropriate prescription for a client diagnosed with heart failure. This is a loop diuretic that promotes the excretion of excess fluid and decreases blood volume and pressure in the left ventricle. 2) Reducing the sodium intake is an appropriate prescription. Because extracellular fluid is primarily regulated by sodium, a low-sodium diet may decrease excess fluid volume. 4) Placing the client on oxygen is an appropriate prescription. The client may have impaired gas exchange and develop hypoxemia depending on the severity of the heart failure.

A tornado was on the ground through a populated area, causing multiple injuries. Which client does the nurse see first? 1. A client with a small penetrating abdominal wound caused by flying debris. 2. A client with blunt trauma to the abdomen that caused bruising. 3. A client reporting chest pain with asymmetrical chest movement noted. 4. A client who is confused and restless with no visible injuries

3)CORRECT - The asymmetrical chest movement indicates flail chest. Monitor the client for shock, give humidified oxygen, manage pain, monitor ABGs. 1) The abdominal wound may cause bleeding. However, the injury does not appear to be life-threatening. 2) This is the second client that should be seen. The observed ecchymosis indicates retroperitoneal bleeding into the abdominal wall. Observe for signs of internal abdominal bleeding. 4) This client appears to be the most stable. However, assess for head injury. The symptoms are most likely related to psychological shock.

The community health nurse plans visits for the day. Which client does the nurse see FIRST? 1. A client reporting a GI upset after taking chlorpropamide. 2. A client reporting vomiting after chemotherapy. 3. A client with a tonometer reading of 21 mm Hg. 4. A client reporting a greenish-yellow discharge from a laryngectomy.

4) CORRECT - This client is unstable due to a possible infection and requires immediate attention. Assess breath sounds and amount, color, and character of drainage before reporting to the health care provider. 1) Chlorpropamide is an oral hypoglycemic. Adverse effects include diarrhea, GI upset, and hypoglycemia, and the medication must be administered in divided doses to relieve GI upset. This client does not require immediate attention. 2) Nausea and vomiting are common adverse effects of chemotherapy. This client does not require immediate attention. 3) A tonometer is a test used to diagnose glaucoma. The tonometer measures intra-ocular pressure, and a normal IOP reading is 10 to 21 mm Hg. This client does not require immediate attention.

The nurse assesses a client who received a blunt head injury from a motorcycle crash. Which finding indicates a basal skull fracture? 1. Periorbital edema. 2. Epistaxis. 3. Purulent drainage from the auditory canal. 4. Bloody or clear drainage from the auditory canal.

4) CORRECT — Bloody or clear drainage from the auditory canal indicates a cerebrospinal fluid leak following trauma and suggests a basal skull fracture. 1) INCORRECT — Periorbital edema is not specific to a basal skull fracture. 2) INCORRECT — A nosebleed is not specific to a basal skull fracture. 3) INCORRECT — Purulent drainage from the auditory canal is not specific to a basal skull fracture. It may indicate an ear infection.

The nurse assesses a client who received a blunt head injury from a motorcycle crash. Which finding indicates a basal skull fracture? 1. Periorbital edema. 2. Epistaxis. 3. Purulent drainage from the auditory canal. 4. Bloody or clear drainage from the auditory canal.

4) CORRECT — Bloody or clear drainage from the auditory canal indicates a cerebrospinal fluid leak following trauma and suggests a basal skull fracture. 1) INCORRECT — Periorbital edema is not specific to a basal skull fracture. 2) INCORRECT — A nosebleed is not specific to a basal skull fracture. 3) INCORRECT — Purulent drainage from the auditory canal is not specific to a basal skull fracture. It may indicate an ear infection.

The nurse provides care for a client in an outpatient clinic who reports vaginal itching. Which recommendation to the client by the nurse is appropriate? 1. "Supplement your diet with yogurt and dairy products." 2. "Douche with an over-the-counter preparation." 3. "Wash the area with soap and water several times a day." 4. "Wear underwear that is lined with a cotton crotch."

4) CORRECT — Cotton-lined underwear is more absorbent and allows for better circulation of air to the body. Dampness aggravates itching. 1) INCORRECT — These foods contain bacilli that naturally exist in the gastrointestinal tract, but they have no effect on vaginal pH. 2) INCORRECT — Douching may alleviate discomfort of vaginal discharge but would disrupt normal pH of the vagina. Douching is not recommended. 3) INCORRECT — This frequency of washing would cause dryness and increase itching in the vaginal area.

A client receives gentamicin 500 mg every 8 hours IV for a leg infection. The nurse touches the client's shoulder when there is no response to a greeting. The client jumps and acts startled. Which action by the nurse is most important? 1. Ask what the client is thinking. 2. Monitor the color and sensation in the client's leg. 3. Obtain the client's temperature, pulse, and blood pressure. 4. Check the client for tinnitus and hearing loss.

4) CORRECT— Ototoxicity is a serious adverse effect of the aminoglycosides such as gentamicin. The client needs to be assessed for hearing loss. 1) INCORRECT — This approach does not address the reason the client was nonresponsive to the nurse's greeting. 2) INCORRECT — Although this might be a good action, it does not recognize that assessment is needed because of the medication a client is receiving. 3) INCORRECT — The nurse may take the client's vital signs. However, the issue is why the client didn't hear or respond to the nurse.

A patient is experiencing Heparin-Induced Thrombocytopenia from Heparin therapy. The doctor orders Heparin to be discontinued. The patient will most likely be placed on what other medication?* A. Argatroban B. Lovenox C. Levophed D. Tridil

A is correct. Angiomax or Argatroban is used when a patient on heparin develops heparin induced thrombocytopenia.

A client is admitted with sickle cell crises and sequestration. Upon assessing the client, the nurse would expect to find: ❍ A. Decreased blood pressure ❍ B. Moist mucus membranes ❍ C. Decreased respirations ❍ D. Increased blood pressure

A is correct. Hypovolemia is a common problem of patients with SCD in crisis. This is manifested as decreased BP

Lidocaine is a medication frequently ordered for the client experiencing A) Atrial Tachycardia B) Ventricular Tachycardia C) Heart block D) Ventricular bradycardia

Ans : B. Lidocaine is used to treat ventricular tachycardia. This medication slowly exerts an antiarrrhythmic effect by increasing the electric stimulation threshold of the ventricles without depressing the force of ventricular contractions.

AV Blocks 1. The nurse in cardiac unit noticed abnormal wave form on cardiac monitor and concluded it is 2nd degree AV block because she knows that the hallmark of 2nd degree type1 AV block is A. Prolonged ST segment B. Elongation of T waves C. Cyclic lengthening of PR intervals D. Abnormally long PR interval.

Answer C

A client has been receiving Rheumatrex (methotrexate) for severe rheumatoid arthritis. The nurse should tell the client to avoid taking: ❍ A. Aspirin ❍ B. Multivitamins ❍ C. Omega 3 fish oils ❍ D. Acetaminophen

Although B is also correct because multivitamin contains folic acid, and methotrexate is folic acid antagonist, the most suitable answer here is A. Should not be given together with NSAIDS for risk of bone marrow depression and toxicity effect.

When gathering evidence from a victim of rape, the nurse should place the victim's clothing in a: ❍ A. Plastic zip-lock bag ❍ B. Rubber tote ❍ C. Paper bag ❍ D. Padded manila envelope

Answer C is correct. A paper bag should be used for the victim's clothing because it will allow the clothes to dry without destroying evidence. Answers A and B are incorrect because plastic and rubber retain moisture that can deteriorate evidence. AnswerD is incorrect because padded envelopes are plastic lined, and plastic retains moisture that can deteriorate evidence.

Which medication prescriptions should the nurse question? (Select All That Apply) 1. Cephalexin for a client with severe allergy to penicillin 2. Fexofenadine for a client with hives 3. Ibuprofen for a client with asthma and nasal polyps 4. Lisinopril for a client with diabetes mellitus 5. Propranolol for a client with asthma

Answer is 1,3,5.

When monitoring an infant with a left-to-right-sided heart shunt, which findings would the nurse expect during the physical assessment? Select all that apply. 1. Clubbing of fingertips 2. Cyanosis when crying 3. Diaphoresis during feedings 4. Heart murmur 5. Poor weight gain

Answer: 345 Congenital heart defects that cause blood to shunt from the higher pressure left side of the heart to the lower pressure right side (eg, patent ductus arteriosus, atrial septal defect, ventricular septal defect) increase pulmonary blood flow. Left-to-right shunting results in pulmonary congestion, causing increased work of breathing and decreased lung compliance. Compensatory mechanisms (eg, tachycardia, diaphoresis) result from sympathetic stimulation. Clinical manifestations of acyanotic defects may include: Tachypnea Tachycardia, even at rest Diaphoresis during feeding or exertion (Option 3) Heart murmur or extra heart sounds (Option 4) Signs of congestive heart failure Increased metabolic rate with poor weight gain (Option 5) (Option 1) Clubbing of the fingertips is associated with chronic hypoxia caused by decreased pulmonary circulation as occurs with right-to-left heart defects. (Option 2) Right-to-left congenital heart defects (eg, cyanotic defects) impede pulmonary blood flow (eg, tetralogy of Fallot, transposition of the great vessels) and cause cyanosis, which is evident shortly after birth and during periods of physical exertion.

Which transmission occurs when an infected person sneezes, coughs, or laugh that is usually projected at a distance of 3 feet? A. Droplet transmission B. Airborne transmission C. Vehicle transmission D. Vector borne transmission

Answer: A

The nurse is ready to begin an exam on a 9-month-old infant. The childis sitting in his mother's lap. Which should the nurse do first? ❍ A. Check the Babinski reflex ❍ B. Listen to the heart and lung sounds ❍ C. Palpate the abdomen ❍ D. Check tympanic membranes

Answer: B

Tensilon test has been ordered for a patient with muscle weakness. The nurse should know that the most common reason for the test is to A. Test for ascending muscle weakness B. Test for generalized muscle weakness with resting tremors C. Differentiate between myasthenia gravis and other conditions that cause weakness D. Differentiate Guillain Barre syndrome from other conditions that cause weakness.

Answer: C

How does exposure to lead cause damage in the developing child? A. Bone demineralization B. Decreased lipid peroxidation C. Increased reactive oxygen species D. Increased action of glutathione reductase

Answer: C; Exposure to lead causes an increase in reactive oxygen species, which is the major mechanism by which damage is caused in the developing child. Lead does not cause bone demineralization, but the lead is stored in the bones. Lead causes increased, not decreased, lipid peroxidation. It also decreases, not increases the action of glutathione reductase.

The nurse is caring for a 2-year-old who is receiving a saline enema for treatment of intussusception. Which client finding is most important to report to the supervisory registered nurse? 1. Passed a normal brown stool 2. Passed a stool mixed with blood 3. Stopped crying 4. Vomited a third time

Answer:1 Most cases of intussusception are treated successfully without surgery using hydrostatic (saline) or pneumatic (air) enema. The nurse will monitor for passage of normal brown stool, indicating reduction of intussusception. If this occurs, the supervisory registered nurse should be notified immediately to modify the plan of care and stop all plans for surgery. (Option 2) In intussusception, the stools are mixed with blood and mucus, giving a characteristic "currant jelly" appearance. This is an expected finding. (Option 3) Pain in intussusception is typically intermittent, occurs every 15-20 minutes, and is accompanied by screaming and drawing up of the knees. Therefore, if a child stops crying, it may due to a short-term intermission from painful spasms rather than reduction of intussusception. (Option 4) Intense pain causes spasms of the pyloric muscle that lead to vomiting after each episode. Vomiting tends to resolve once the intussusception is reduced.

Which type of endotracheal tube is recommended by the Centers for Disease Control (CDC) for reducing the risk of ventilator associated pneumonia? ❍ A. Uncuffed ❍ B. CASS ❍ C. Fenestrated ❍ D. Nasotracheal

B

The nurse manager who is responsible for hiring professional nursing staff is required to comply with the Americans with Disabilities Act. The provisions of the law require the nurse manager to A) Maintain an environment free from hazards B) Provide reasonable accommodations for disabled individuals C) Make all necessary accommodations for disabled individuals D) Consider only physical disabilities in making employment decisions

B is correct. Unlike the Civil Rights Act, the ADA also requires covered employers to provide reasonable accommodations to employees with disabilities, and imposes accessibility requirements on public accommodations. A reasonable accommodation according to ADA is a change in the way things are typically done that the person needs because of a disability, and can include, among other things, special equipment that allows the person to perform the job, scheduling changes, and changes to the way work assignments are chosen or communicated.

A nurse is to administer iv insulin in 500mls of D5W at the rate of 100mls/hr. When will the nurse draw the peak level if she is to hang the bag at 10a.m? A. 3 pm B. 3.30 pm C. 10.30 a.m D. 10 a.m

B is the correct answer. Trough level is drawn 30 minutes before administration of drugs with narrow therapeutic window irrespective of route. But peak level is drawn 5-10minutes after an oral drug dissolves; 15-30minutes after IV drug is finished. For insulin, if the type is given, consider the peak time of the type from the time the iv push or infusion is finished. If the type is not given, the rule for iv drugs applies. Since the infusion rate is 100mls/hr, the infusion will last 5hrs. From 10 a.m. to 3pm. Then 15-30minutes after, draw peak level. The only correct option in the question is 3.30pm - B

The nurse is teaching a client with polycythemia vera about potential complications from this disease. Which manifestations would the nurse include in the client's teaching plan? SATA A. Hearing loss B. Visual disturbance C. Headache D. Orthopnea E. Gout F. Weight loss

Correct answers are BCDE...polycythemia vera. A condition in which too many rbc's are produced in the blood serum, can lead to an increase in the hematocrit and hyperkalemia, hyperviscosity and hypertension. The client may experience dizziness, tinnitus,visual disturbances, headaches, or a feeling of fullness in the head. The client may also experience cardiovascular symtoms such as heart failure shortness of breath and orthopnea, increased clotting time or symptoms of an increased uric acid level such as painful swollen joints( usually the big toe). Hearing and weight loss are not manifestations associated with polycythemia vera

Select all that apply that is appropriate when there is a benzodiazepine overdose: A. Administration of syrup of ipecac B. Gastric lavage C. Activated charcoal and saline cathartic D. Hemodialysis E. Administration of flumazenil

Correct answers are BCE..if ingestion is recent decontamination of the GI system is indicated. Administration of Syria of ipecac is contradicted because of aspiration risks related to sedation. Gastric lavage is general the best and most effective means of gastric decontamination. Activated charcoal and a saline cathartic may be administered to remove any remaining drug. Fumazinil can be used used to acutely reverse the sedative effects of benzodiazepines, though this is normally done only in cases of extreme overdose or sedation.

Which of the following guidelines should be least considered in formulating objectives for nursing care? A Written nursing care plan B Holistic approach C Prescribed standards D Staff preferences

D is correct. Staff preferences should be the least priority in formulating objectives of nursing care. Individual preferences should be subordinate to the interest of the patients.

Nclex Question On entry after report in a patient's room, the nurse has noticed that the TPN solution for the patient is running at incorrect rate and now 2 hours behind schedule. What should the safe nurse do immediately? 1. Immediately double the infusion rate for one hour and then slow it down 2. Immediately correct the rate and notify the Physician 3. Stop the infusion immediately 4. Notify the Physician immediately

The Correct Answer is 4. Explanation: Notify immediately the physician is the safest action for the nurse here. Correcting TPN administration to normal rate can cause the patient go into rebound hypo or hyper-glycemia which could further bring fatal complications. Also this is a deadly incidental situation where the nurse must need a new order at a rate definitely different than the infusion rate ordered in the first place. This nclex kind of safety question tests the nurse's ability of safe practice.

Nclex Question On entry after report in a patient's room, the nurse has noticed that the TPN solution for the patient is running at incorrect rate and now 2 hours behind schedule. What should the safe nurse do immediately? 1. Immediately double the infusion rate for one hour and then slow it down 2. Immediately correct the rate and notify the Physician 3. Stop the infusion immediately 4. Notify the Physician immediately

The Correct Answer is 4. Explanation: Notify immediately the physician is the safest action for the nurse here. Correcting TPN administration to normal rate can cause the patient go into rebound hypo or hyper-glycemia which could further bring fatal complications. Also this is a deadly incidental situation where the nurse must need a new order at the rate definitely different than the infusion rate ordered in a first place. This nclex kind of safety question tests the nurse's ability of safe practice. Good Content learning. Good job everyone.

The nurse is assisting with prenatal testing in a patient who is 15 weeks pregnant. Amniocentesis reveals the fetus to have fragile X syndrome. Which of the following statements by the nurse to the patient is most accurate? A. "Fragile X syndrome more frequently affects males." B. "Fragile X syndrome more frequently affects females." C. "Individual's with fragile X syndrome are genotypically females but phenotypically males." D. "Individual's with fragile X syndrome are genotypically males but phenotypically females."

The answer is A. Fragile X syndrome, which is characterized by unstable portions of the X chromosome affects males twice as frequently as females (1 in 4000 for males, 1 in 8000 for females) because females have two copies of the X chromosome. Therefore, if there is an error on one copy of the gene for fragile X syndrome, normal genes on the other copy of the X chromosome that is present in females can be expressed. Symptoms include characteristic facial dysmorphology, mental retardation, and social impairments. Fragile X syndrome does not cause alterations in the phenotypical sex characteristics.

The patient with major depressive disorder asks the nurse what causes the symptoms of depression. While the precise cause of depression is unknown, which response by the nurse is appropriate? A. "There is too much dopamine and serotonin in your brain." B. "Your brain does not produce enough norepinephrine or dopamine." C. "Your symptoms are caused by a lack of epinephrine and serotonin." D. "Enzymes in your brain do not break down dopamine or norepinephrine quickly enough."

The answer is B, "Your brain does not produce enough norepinephrine or dopamine." Rational: Major depressive disorder is caused by decreased dopamine, norepinephrine, or serotonin (or a combination of the three) available to receptors in the brain. Mania is caused by an excess of these neurotransmitters; this can also occur when the enzymes in the brain do not break down dopamine or norepinephrine quickly enough. Epinephrine is not a neurotransmitter implicated in depression.

The nurse teaches the mother of a newborn that in order to prevent SIDS the best position to place baby after nursing is? SATA A. Prone B. Side-lying C. Supine D. Fowler's

The correct answers are B,C..Research demonstrates that the occurrence of SIDS is reduced with these two positions.