NCLEX review 1

CO2 lab value

35-45 > 60's it is a D (Bad)

PO2 lab value

78-100 < 60's it is a D (Bad)

Purpose of a defense mechanism is to reduce________?

Anxiety

Hyponatremia=_______?

fluid overload

Platelet lab value

150,000 - 400,000 <40,000 it is a D (Bad)

How long do antidepressants take to provide beneficial effects?

2-4 weeks

Lithium toxicity occurs when blood levels are higher than____ mEq/L

2.0

The Doc orders IV nalbuphine (Nubain) for a primigravid client in early active labor. After administering the drug, which of the following should the nurse do first? A: Elevate the head of the bed B: Cover the client with a blanket C: Pull side rails up D: Dim the lights

C- Nalbuphine is an analgesic that is used in labor. It has a sedative effect and can slow resp rate.

After a transurethral resection of the prostate, the nurse notices that the client's urine is bright red, has numerous clots, and is viscous. Which nursing action is most appropriate? A: Irrigate the catheter to remove clots B: Milk the catheter tube vigorously C: Increase the client's fluid intake D: Assess VS and notify the surgeon

D- Blood clots are normal but bright red blood could mean a hemorrhage.

K+ lab value

3.5-5.3, > 6 it is D(Bad)

While assessing a four day old neonate delivered at 28 wks gestation, the nurse cannot elicit the neonate's Moro reflex, which was present 1 hour after birth. The nurse notifies the doc because this may indicate which of the following? A: Postnatal asphyxia B: Skull fracture C: Intracranial hemorrhage D: Facial nerve paralysis

C- When the nurse cannot elicit the Moro reflex of a four day old intracranial hemorrhage or cerebral edema should be suspected.

The first sign of CVA is usually a_____?

Change in LOC

The client is on simvastatin (Zocor) as a component of cholesterol management. Which of the following lab tests needs to e monitored while on this therapy? A: CBC B: Serum glucose C: Total protein D: Liver function test

D- If AST lvl's rise to 3X normal therapy should be discontinued.

PH lab value

7.35-7.45, Less than < 7 it is a D(Bad)

The nurse is providing discharge instructions to the client with peripheral vascular problems. Which of the following instructions should be included? SATA: A: Avoiding prolonged standing and sitting B: Limiting walking so as not to activate the "muscle Pump" C: Keeping extremities elevated on pillows D: Keeping the legs in a dependent position E: Using a heating pad to promote vasodilation

A, C- Elevating the extremities counteracts the forces of gravity and promotes venous return. Walking is encouraged to activate the muscle pump ad promote collateral circulation.

A 58 year old is brought to the ER by the police after being found unconscious on the street. Following examination a diagnosis of diabetic ketoacidosis is confirmed. Which of the following info is most crucial to document on the client's chart? SATA: A: Size of pupils and reaction of pupils to light B: Response to verbal and painful stimuli C: Skin condition and presence of any rashes, lesions, or ulcers D: BP E: Length of time the client has had diabetes F: Hourly urine output

A,B,C,D,F- pg 904 question 118 for reason

The nurse should prepare the client for which of the following during the immediate postoperative care after reversal of a colostomy? SATA: A: NG tube attached to low intermittent suction B: Administration of I.V. fluids C: Daily measurement of ABD girth D: Calculation of I/O every 8 hours E: Assessment of vital signs every 6 hours

A,B,D- After bowel surgery, an NG tube attached to low suction is used to remove gastric fluids. The amount of fluid from the NG suction is important for electrolyte balance.

The nurse is caring for an elderly client who has experienced a sensorineural hearing loss. The nurse anticipates that the client will exhibit which one of the following symptoms? A: Difficulty hearing high pitched sounds B: Difficulty with speaking clearly C: Inability to assign meaning to sound D: Vertigo when changing positions

A- The client with sensorineural hearing loss has difficulty hearing high pitched sounds. Aging and ototoxicity are two causes of sensorineural hearing loss.

The nurse should establish baseline data on a client who is starting on long-term gentamicin sulfate therapy. Which of the following is least important for assessment screening in this client? A: Visual acuity B: Vestibular function C: Renal function D: Auditory function

A- Visual acuity is not affected by long term gentamicin therapy.

The nurse is developing a plan of care for a client who has joint stiffness due to RA. Which of the following interventions is most effective in relieving stiffness? A: A warm shower before performing ADL's B: Aspirin after activity to decrease inflammation C: A 10 Ib weight loss to limit stress on joints D: Cold compresses to joints for 30 mins to relieve stiffness.

A- Warm showers, baths, or hand soaks can help relieve joint stiffness and allow the client to more comfortably perform ADL's.

Which of the following meals would be appropriate for the child with osteomyelitis to choose? A: Beef an bean burrito with cheese, carrot and celery sticks, and an orange. B: Buttered wheat bread, cream of broccoli soup, tossed salad with dressing, and an apple. C: Potato soup; BLT; and an orange. D: Tomato soup, grilled cheese sandwich, and banana

A- children with osteomyelitis need a diet that is high in protein and calories.

A mother tells a nurse that her child has been exposed to roseola. After teaching the mother about the illness, which of the following, if stated by the mother as the most characteristic sign of roseola, indicates successful teaching? A: Fever and sore throat B: Normal temp followed by a low grade fever C: High fever followed by a drop and then a rash D: Cold like signs and symptoms and a rash

C- Children with roseola have a high fever for three days which drops suddenly. Then a nonpruritic rash appears for about one to two days.

A client with cholecystits is taking Pro-pantheline bromide (Pro-Banthine). The expected outcome of this drug is: A: Increase bile production B: Decreased biliary spasm C: Absence of infection D: Relief from nausea

Answer: B- Propantheline bromide is an anticholinergic used to decrease biliary spasm. This decreases pain.

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should assess the client for which alteration in fluid and electrolyte balance? A: Increased osmolality of the plasma B: Decreased serum sodium level C: Increased urine output D: Decreased blood pressure

Answer: B- SIADH is characterized by excess antidiuretic hormone secretion, despite low plasma osmolality. Excess ADH causes water to be retained.

The unit secretary who transcribes the physicians orders asks the nurse to interpret an illegible order. The nurse should: A: Interpret the order according to the clients previous medication record. B: Clarify with the pharmacist C: Clarify with the physician D: Clarify with the clients family.

Answer: C

A client is taking phenytoin (Dilantin) as an antiepileptic medication. The nurse should instruct the client to obtain: A: Increased iron B: Increased Calcium C: Frequent dental examinations D: Frequent eye examinations

Answer: C- phenytoin causes hyperplasia of the gums.

After a bronchoscopy with biopsy the nurse assesses the client. Which of the signs should be reported immediately to the physician? A: Green sputum B: Dry cough C: Hemoptysis D: Laryngeal stridor.

Answer: D- Laryngeal stridor is characteristic of respiratory distress from inflammation and swelling after a bronchoscopy.

Monoamine Oxidase inhibitors are ______? All have ______, _________, and ______ in the name.

Antidepressants, Mar, Nar, Par

The nurse instructs the client with osteoporosis that food products high in calcium include: A: Rice B: Broccoli C: Apples D: Meats

B

When developing a nutritional plan for a child who needs to increase protein intake, the nurse should suggest which of the following foods? Select all that apply: A: Bacon B: Cooked dry beans C: Peanut Butter D: Yogurt E: Apple

B, C, D- all contain good amount of protein. Bacon= fat, Apple= Carbs

A client who has asthma is taking albuterol to treat bronchospasms. The nurse should assess the client for which of the following adverse effects that can occur as a result of taking this drug? SATA: A: Lethargy B: Nausea C: Headache D: Nervousness E: Constipation

B,C,D- Albuterol is a beta-adrenergic agonist.

A toddler admitted in respiratory distress keeps pulling at the oxygen mask. The nurse should? SATA: A: Restrain the child B: Have the parent read to the child C: Administer a sedative D: Encourage the parent to hold the child E: Tell the child the mask will help him breathe better F: Ask the parent to leave the child's bedside

B,D- Children in resp distress need to be kept as quiet as possible to decrease resp and heart rates.

You find a client who has just had surgery is diaphoretic, appears to have no respirations, and has a barely palpable pulse. What is the most appropriate immediate response? A: Call a code B: Open the airway C: start rescue breathing D: start cardiac compressions

B- ABC's

Which of the following complications is associated with a tracheostomy? A: Decreased CO B: Damage to the laryngeal nerve C: Pneumothorax D: Acute respiratory distress syndrome

B- Trachs are associated with several potential complication, including nerve damage, bleeding and infection.

Foods that contain Tyramine are?

B-bananas A-avacados R-raisins (dried fruits) No organ meats or preserved meats No cheese except mozzarella and cottage cheese No Alcohol

Client is taking large doses of aspirin daily to treat her RA. Which of the following side effects should she be instructed to report? A: Abd cramps B: Tinnitus C: Rash D: Hypotension

B: Aspirin is ototoxic.

What is the most important thing to do immediately when retinal detachment is suspected?

Bedrest

A client with end stage cancer who is receiving chemo tells her husband that she feels useless now and wants to die. Prioritize the following statements starting with first priority. A: I will assess your wife to determine if she is suicidal B: She may feel differently when her chemo is completed C: Thanks for telling me this; it must be scary to have her tell you this D: Let's discuss what you can say to her that may help.

C,D, A, B- First acknowledge feelings, then learn to talk to wife, then assess for suicide.

In a patient with hpercalcemia, which monitor pattern would be the most likely threat? A: Paroxysmal atrial tachycardia with decreased ST segments B: Bradycardia with second degree Mobitz type II block and elevated ST segment C: Frequent PAC's with multifocal coupling of PVC's and tall T-waves D: First degree heart block with decreased ST segment and inverted T-waves

D- Use arrows!

Hypernatremia=______?

Dehydration

Name the 3 groups of drugs used to treat CHF?

Diuretics, digitalis, vasodilators

Name the three types of CVA's

Embolus, thrombus, hemorrhage

Hyperthyroidism is?

Graves disease

What is hirsutism?

Hair where you don't want it

In Cushings the blood sugar is_______? The sodium level is___________?

Increased in both

What is the classic test for Cystic Fibrosis?

Iontophoresis- Sweat test

Benzodiazepines always have _____and ________ in the name.

Lam and Pam

#1 post-op answer on NCLEX for spinal chord injury

Log Roll

Deconate means?

Long acting IM form

What two systems organs are the most problems in CF?

Lungs, pancreas

Tricyclic antidepressants are______?

Mood elevators to treat depression

All aminoglycosides end in _________? Except if the have ______ in the name.

Mycin, Thro

Calcemias do the _______ the prefix. No exceptions.

Opposite

Toxic effects of aminoglycosides include________?

Ototoxic, Nephrotoxic.

What complication is common in CHF?

Pulmonary edema

What does right-sided CHF mean? Left?

Right ventricle has decompensated, Left ventricle has decompensated

Kalemias do the _______ as the prefix except for ______ and _________

Same, heart rate, urine output

What group of drugs are given to people with retinal detachment?

Tranquilizers

The signs of lithium toxicity are_______ , ________ , and thirst

Tremor, nausea and vomiting

Atrial fibrillation increases risk of CVA? (T/F)

True, emboli particularly

Patients on MAOI's must avoid foods containing_______?

Tyramine

What visual experiences will patients with digitalis toxicity have?

Yellow/green halos around lights

Is Cystic Fibrosis hereditary?

Yes

Phenothiazines all end in______? Large doses are______? Small doses are_________?

Zine, Antipsychotic, Antiemetic

All psych drugs cause_______?

low BP & weight change