NCLEX Review
In what order should the nurse address these client events that occur at the same time? Place in order of highest to lowest priority.
1. Client's tracheostomy needs to be suctioned (airway problem) 2. The water seal chamber is empty in a client's closed chest drainage unit (breathing problem) 3. UAP reports a heart rate of 40/min in a client (circulating problem) 4. Client admitted with deep vein thrombus asking why complete bedrest has been prescribed (if the client gets up and ambulates, the clot can break lose and form an embolus) 5. Client reporting urinary frequency and dysuria (not a life-threatening problem)
In what order should a nurse assess the clients assigned? Place in order from first to last.
1. Client diagnosed with acute pancreatitis reporting umbilical pain 8/10 despite medication. WBC-11,000/mcl (11.0 x 10/L, GI-210 mg/dL. New prescription for placement of NG tube to low suction. 2. Cachectic client with abdominal pain, severe diarrhea, and abdominal tenderness to palpation. Total parenteral nutrition via a central line is being administered. (could lead to fluid volume deficit or shock) 3. Client diagnosed with diverticulitis receiving IV antibiotics and has a prescription to discontinue the NG tube to low suction (client is improving if NG tube can be removed) 4. Client who had a percutaneous endoscopic gastrostomy inserted 3 days ago and has a prescription to begin intermittent tube feeding (client is stable) 5. Client scheduled to be discharged one day post appendectomy (most stable client)
8. A pediatric registered nurse has been pulled to the adult medical-surgical unit. Which clients should the charge nurse assign to this nurse? Select all that apply. 1. Client who had a percutaneous endoscopic gastrostomy inserted 3 days ago (pediatric clients can have a percutaneous endoscopic gastrostomy, so the pediatric nurse can care for this client; stable) 2. Cachectic client with abdominal pain, severe diarrhea and is receiving TPN (this client is complicated and unstable due to severe diarrhea which could lead to shock) 3. Client receiving IV antibiotics for pneumonia (a pediatric nurse can give IV antibiotics. Pediatric clients can be admitted to the pediatric unit with pneumonia) 4. Client diagnosed with acute pancreatitis who is NPO with a NG to low suction and IV administration (client is unstable; acute pancreatitis client's can deteriorate rapidly) 5. Client admitted 2 hours ago with a diagnosis of acute cholecystitis (RNs can cure for routine, stable clients who may go to surgery for a lap cholecystectomy)
1. Client who had a percutaneous endoscopic gastrostomy inserted 3 days ago 3. Client receiving IV antibiotics for pneumonia 5. Client admitted 2 hours ago with a diagnosis of acute cholecystitis
A nurse is performing open bladder irrigation using a two-way indwelling catheter. In what order will the nurse perform this procedure?
1. Perform hand hygiene 2. Using aseptic technique, open supplies and pour irrigating solution into sterile basin 3. Place disposable water-resistant towel under the catheter 4. Apply clean gloves 5. Disconnect catheter from drainage tubing and place catheter end in sterile basin 6. Draw prescribed amount of irrigating solution into syringe 7. Insert tip of syringe into catheter opening 8. Irrigate bladder gently and slowly
Upon arrival to the emergency department, a client tells the nurse, "I may have the Ebola virus." What evidence would the nurse assess for in the client who has contracted this virus? Select all that apply. 1. Reports severe headache and muscle pain <— (s/s include: fever [greater than 101.5 degrees F or 38.5 degrees C], severe headache, muscle pain, weakness, diarrhea, vomiting, abdominal pain, and unexplained hemorrhage [bleeding or bruising) 2. Unexplained bruising noted <— (common symptom) 3. Temperature of 99 degrees F (37.2 degrees C) (the client with EVB would exhibit a fever greater than 101.5 degrees F or 38.5 degrees C) 4. Returned 1 week ago from the Philippines (West African countries, rather than Oriental countries, are high risk ares of travel) 5. Participated in West African burial ritual (can expose a person to EVB, as a person can come into contact with blood and body fluid)
1. Reports severe headache and muscle pain 2. Unexplained bruising noted 5. Participated in West African burial ritual
What should a nurse teach a group of teenage boys who admit to using smokeless tobacco? Select all that apply. 1. Smokeless tobacco increases risk for lung cancer (smokeless tobacco is not inhaled so it doesn't increase the risk of lung cancer) 2. Inspect mouth frequently for lesions <— (smokeless tobacco does increase the risk of mouth cancer; part of the GI system) 3. White patches in mouth should be reported to primary healthcare provider <— (white patches [leukoplakia] is a sign of potential oral cancer; part of our GI system) 4. Risk of stomach cancer can be decreased by not swallowing smokeless tobacco juice (some amount of tobacco juice will be swallowed) 5. Report decreased saliva to primary healthcare provider (decreased saliva isn't a sign of oral cancer) 6. Information about smoking cessation classes <— (beneficial for clients)
2. Inspect mouth frequently for lesions 3. White patches in mouth should be reported to primary healthcare provider 6. Information about smoking cessation classes
A teenage client with asthma reports becoming very anxious and fearful each time an asthma attack occurs. What would be the BEST response to this client? 1. "You are probably over-reacting to a simple flare-up of asthma. You don't need to worry yourself like that." 2. "The feelings that you described are normal emotions in individuals with asthma. You may find that learning and practicing relaxation exercises may be helpful." 3. "I am concerned because you are old enough that you should understand asthma and not be experiencing these feelings. I suggest that you consult a psychiatrist to help you cope." 4. "Everyone with asthma experiences tough times with their symptoms. I think you are doing great managing your asthma."
2. "The feelings that you described are normal emotions in individuals with asthma. You may find that learning and practicing relaxation exercises may be helpful."
What assessments would be appropriate for the school nurse to perform when carrying out responsibilities for school safety practices and emergency preparedness? Select all that apply. 1. Teach about laws of gun control (intervention, not an assessment) 2. Observe for gaps or changes in levels of sidewalks 3. Identify which students have special healthcare needs 4. Locate all entrances and exits to buildings 5. Identify historical threats and hazards in the school and surrounding community 6. Perform a check of all fire extinguishers
2. Observe for gaps or changes in levels of sidewalks 3. Identify which students have special healthcare needs 4. Locate all entrances and exits to buildings 5. Identify historical threats and hazards in the school and surrounding community 6. Perform a check of all fire extinguishers
4. A concerned parent is asking the nurse about activities that would be best for a child who has been diagnosed with asthma. Which activity should the nurse suggest for the child in order to minimize the risk of exercise induced asthma symptoms? 1. Track 2. Basketbal 3. Baseball (asthma friendly) 4. Soccer
3. Baseball
The primary healthcare provider has prescribed Heparin 5000 units subcutaneously every 12 hours. The nurse is to adjust the dosage based on the dosing chart provided. How much heparin should the nurse administer to the client weighing 176 pounds if the PTT is 53 sec? (Round to the nearest 500 units).
7000 units every 12 hours Current dosage is 5000 units every 12 hours Since the PTT is 53, based on the dosing adjustment scale, the client's dose should be increased by 24 units/kg every 12 hours Client's weight is 176 pounds / 2.2 = 80 kg Increase dosage by 24 units X 80 kg = 1,920 units (Rounded off to the nearest 500 = 2000 units increase every 12 hours) Current dose of 5000 units every 12 hours + 2000 unit increase = 7000 units every 12 hours
