Kelso's NCLEX Question Rationales
What nursing interventions are necessary when giving Phenytoin (Dilantin) for seizure prophylaxis?
- Give as I.V. bolus no faster than 50mg/minute - Monitor ECG, blood pressure, and respiratory status continuously when giving via I.V. - Know that early toxicity may cause drowsiness, nausea, vomiting, nystagmus, ataxia, dysarthria, tremors, and slurred speech - Later, hypotension, arrhythmias, respiratory depression, and coma - Death is caused by respiratory and circulatory depression
In Normal Sinus Rhythm, the heart rhythm is considered normal, even after a PAC, as long as:
- The rate does not exceed 100bpm - P waves are identifiable - PR interval is 0.20 seconds or less
40mg of Lasix should be pushed over what period of time?
1 - 2 minutes
Delusions that the doctor is talking to the CIA, nurses response
"I don't know anything about the CIA. Do you feel afraid that people are trying to hurt you?" Person truly believes what they think is real. Disagreeing with they client may make them more defensive.
A nurse is assessing a client who is a pilot for an interstate commuter airline. This client tells the nurse that he uses illegal drugs for recreational purposes every weekend. Using the ethical principle of nonmaleficence to guide her reaction with the client, what should the nurse say?
"I want you to think about how an error in judgment could cause a serious accident." - Nonmaleficence: The obligation to do no harm to another
Bicuspid Aortic Valve Location
*** LOCATED at the 3 cusps going into the LEFT VENTRICLE*** • Located between the LEFT VENTRICLE and the AORTA • It is one of the semilunar valves • Has 3 cusps • Risk for Aortic Stenosis and Aortic Regurgitation • Impaired blood flow through the valve leads to INCREASED pumping pressure of the LEFT VENTRICLE
Burns in children differ from that of adults by... ?
- A delay in growth may occur after a burn injury - An immature immune system presents an increased risk of infection - Increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults
Case Management represents an interdisciplinary health care delivery system by:
- Appropriate use of hospital personnel - Appropriate use of hospital material resources to maximize hospital revenues while providing for optimal outcome of care - Case Management manages client care by managing the client care environment.
When teaching a client about Lithium (Lithobid), the nurse should instruct the client to:
- Drink at least six to eight glasses of water per day (to avoid lithium toxicity) - Avoid caffeine (because it increases urine output)
Incentive Spirometer: When maximal inspiration is reached the client should hold the breath for...
2 to 3 seconds and then exhale.
After a procedure a client SHOULD NOT use heat during the first:
24-hours because it may increase localized swelling
Most children with scoliosis must wear a brace until the spine matures -- typically for:
3 to 5 years
A child will remain in a booster seat until what age and height?
8 - 12 years old and 4' 9" tall
Bladder Exstrophy is when the bowel tissue is exposed, what would you cover it with?
A Non-Adhering Plastic Wrap
Which drug may cause significant interactions when given with Cisplatin (Platinol) and what does it cause?
Aminoglycosides It causes nephrotoxicity and ototoxicity.
Antibiotics are not taken prophylactically to prevent symptoms from chlamydial infection:
Antibiotic treatment, if taken exactly as directed, normally cures chlamydia infections, but DOES NOT prevent symptoms.
Permethrin (Elimite), how would you put it on a child with Scabies?
Apply the lotion into all skin surfaces on cool, dry skin at least 30 minutes after bathing
Hypothyroidism S/S
Decreased body temperature and cold intolerance. Decreases the metabolic rate. • ↓HR • ↓BP • ↓Ventilation (hypoventilation) • ↓Body Temperature • ↓Intellectual Function • Dyspnea • Anorexia • Constipation • Depression
For maximum pain relief, when should the nurse give morphine for postoperative abdominal surgery?
Before the pain becomes severe. You do not want to give it around the clock, such as every 3 hours, because you want to be able to see if the patient will need a larger dose because their pain is worsening.
In what position should the nurse place the head of the bed to obtain the most accurate reading of jugular vein distension?
Between 15 - 30 degrees
An abusive husband comes into his wife's room yelling and states he is going to "finish the job." How should the nurse react?
Call a security guard and another staff member for assistance. Ensure personal safety and never attempt to manage a physically aggressive person alone.
If chest tube is accidentally pulled out, after you have applied sterile gauze over the insertion site you should...
Call the physician
Before giving Methergine, what would you check? What is this medication used for?
Check BP Used for Postpartum Hemorrhage caused by uterine atony
Amniotomy increases the risk of:
Cord prolapse -Amniotomy: artificial rupture of membranes (AROM)
Basal Cell Carcinomas are:
Small, waxy nodules with translucent borders.
Dexamethasone (Maxidex Ophthalmic Suspension) exerts its therapeutic effect by:
Decreasing leukocyte infiltration at the site of ocular inflammation. This action reduces the exudative reaction of diseased tissue, lessening edema, redness, and scarring.
A nurse is administering Colchicine to a client who is experiencing an exacerbation of gouty arthritis. The nurse should monitor for which associated adverse reaction?
Diarrhea - When diarrhea occurs, the dosage is reduced or the medication is changed.
Early Decelerations present on fetal heart monitor, what action should the nurse take?
Document the finding and continue to monitor. Normal finding.
Using the process of elimination:
Eliminate options that us close-ended words, such as ALL.
Rubeola (Measles) Nursing Considerations
Eye Care, the usually have photophobia so keep them in a room with dim lighting
Nyctophobia
Fear of darkness
Agoraphobia
Fear of open spaces
What would you see upon assessment of a child with Scabies?
Fine Grayish Red Lines
A prolonged PR-interval is associated with:
First-degree Atrioventricular (AV) block
Malignant Melanoma is usually characterized by:
Flat, irregular border that may be tan, brown, or black
A _______ care plan is needed for any client who behaves in a suspicious, withdrawn, or regressed manner or has a thought disorder; Schizophrenia.
Flexible
Sources of Folic Acid:
Green leafy vegetables Whole grains Fruits Liver Dried peas Beans
Nocturnal Enuresis is common in most children and eventually they...
Grow out of it
The most serious safety threat to a 2-year-old in the hospital is if the crib side rails are in what position?
Halfway, because the most common accidents in the hospital are falls.
Signs of acute (angle-closure) glaucoma
Headache Nausea Redness of the eyes
A nurse assesses an 8 -year-old child and hears a murmur that's barley audible and a heart rate of 80bpm. What would the nurse document?
Heart rate regular, grade I murmur auscultated. HR: 70 - 110 RR: 16 - 22 BP: 95/57
When assessing a child with impetigo, what would the nurse expect to see?
Honey-colored, crusted lesions
Lactulose (Chronulac): What is this medication? What condition is it used for? What lab would you check?
Hyperosmotic Laxative and Ammonia Detoxicant Prevents or treats Portal-Systemic Encephalopathy, including hepatic precoma and coma, also used for constipation Check Ammonia level
When should a nurse obtain a blood sample to measure the trough drug level?
IMMEDIATELY before giving the next dose
Leflunomide (Arava): What is this medication used for and which question would you ask to assess if it is effective?
Immunomodulatory agent which has an anti-inflammatory action. Use: Relief of Rheumatoid Arthritis Pain Question: Do you have any joint pain?
What is the importance of discussing when to administer prophylactic antibiotics to a toddler that has Congenital Heart Disease (CHD)?
In CHD, areas of turbulent blood flow provide an optimal environment for bacterial growth. Therefore, the child with CHD is at increased risk for bacterial endocarditis, an infection of the heart valves and lining, and requires prophylactic antibiotics BEFORE DENTAL WORK and INVASIVE PROCEDURES.
A college student comes to the campus health care center complaining of headache, malaise, and a sore throat that has worsened over the past 10 days. The nurse measures a temperature of 102.6 and finds an enlarged spleen and liver and exudative tonsillitis. Laboratory tests reveals a leukocyte count of 20,000mm, antibodies to Epstein-Barr virus, and abnormal liver function tests. These findings suggest:
Infectious Mononucleosis
Tests to evaluate the function of cranial nerve II (optic nerve):
Snellen chart - assesses distant vision Rosenbaum card - assesses near vision
For a client newly diagnosed with radiation-induced thrombocytopenia, the nurse should include which intervention in the care plan?
Inspecting the skin for petechiae once every shift. Because thrombocytopenia impairs blood clotting, the nurse should inspect the client regularly for signs of bleeding, such as petechiae (small red or purple spot on the body, hemorrhage), purpura (purple or red discolorations on the skin that do not disappear with blanching), epistaxis, and bleeding gums.
A client with a history of PVD has absent pulses; paresthesia; and mottled, cyanotic, and a cold calf. How should the nurse position the leg while the physician makes treatment decisions?
Keep the affected leg level or slightly dependent. *Protect it from pressure and DO NOT use heat or cold compresses because this would further compromise tissue perfusion*
Moments after birth, a neonate of 32 weeks' gestation develops asphyxia (unable to breathe normally). As the neonatal team starts resuscitation, the nurse must:
Keep the neonate's head in the "stiff" position.
As part of a primary cancer prevention program, an oncology nurse answers questions from the public at a health fair. When someone asks about laryngeal cancer, the nurse should explain that:
Laryngeal cancer is one of the most preventable types of cancer.
Stage 1 Phases in the Intrapartum Period
Latent: Longest phase/ 1-4 cm/ Contractions q15-30 min/15-30 sec in duration/Mild intensity Active: 4-7 cm/Contractions q3-5 min/ 30-60 sec in duration/Moderate intensity Transitional: 8-10 cm/ Contractions q2-3 min/45-90 sec in duration/Strong intensity ***It goes LAT downward and the first is LATent*** LAT A T
A client in isolation after receiving an internal radioactive implant to treat cancer. Two hours later, the nurse discovers the implant in the bed linens. What should the nurse do first?
Leave the room and notify the radiation therapy department immediately.
When obtaining the health history from a client with retinal detachment, a nurse expects the client to report:
Light flashes and floaters in front of the eyes
Squamous Cell Carcinomas are:
Malignant lesions generally found on areas of sun-damaged skin (such as the face).
What does the Romberg test assess?
Standing and balance via the vestibular apparatus in the inner ear. It also assesses intactness of the cerebellum and proprioception (awareness of the position of one's own body)
Myasthenia Gravis affects:
Motor function
Early Sign of Increased ICP
Nausea
How would you assess the adequacy of fluid resuscitation in a child with burns who is receiving treatment for burn shock?
Neurological Assessment; Sensorium is an accurate guide to determine the adequacy of fluid resuscitation
A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery is most likely to reverse these manifestations?
Nonrebreather mask
Ethical Principles in Nursing: Nonmaleficence
Obligation to do or cause no harm to another
Ethical Principles in Nursing: Veracity
Obligation to tell the truth
Clonidine (Catapres) can be used to treat hypertension as well ass withdrawal with:
Opioids
Petechiae is best assessed where on a dark-skinned client?
Oral Mucosa Conjunctivae
A notched T-wave may indicate:
Pericarditis
Ticlopidine Hydrochloride (Ticlid): What type of medication is it? What is it used for? What should not be given with this medication?
Platelet Aggregation Inhibitor Decrease Thrombotic Stroke in clients with precursor symptoms AVOID Aspirin
While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first?
Prepare to administer Protamine Sulfate Frank hematuria indicates excessive anticoagulation and bleeding -- and heparin overdose. D/C the heparin infusion and give the antidote
Post Tonsillectomy Position
Prone or Side-Lying to facilitate drainage
Nephrotic Syndrome 4 Main S/S, then other S/S:
Proteinuria Hypoalbuminemia Hyperlipidemia Edema (General or in the Leg, Ankle, Labia, or Scrotum) Anorexia Pallor Weight Gain
Hyperparathyroidism - Risk for injury: R/T...
Related to bone demineralization resulting in pathological fractures. - INCREASED CALCIUM - The increase may diminish calcium stores in the bone, causing bone demineralization and setting the stage for pathologic fractures and a risk for injury.
Ethical Principles in Nursing: Autonomy
Respect for an individual's right to self-determination
A Continuous Subcutaneous Insulin regimen uses a basal rate and boluses of what type of insulin?
Short-Acting Insulin
A client suspected of having colorectal cancer requires which diagnostic study to confirm the diagnosis?
Sigmoidoscopy - used to vizualize the lower GI tract; aids in detection of two-thirds of all colorectal cancers.
When caring for an infant they like to be...
Swaddled/Held Warm Tactile Stimulation Talk to them in a Soft Voice Contrasting Color Mobiles (they like to look at these) DO NOT let them cry for 10 minutes before checking up on them, when they cry go see them
Which ECG changes are signs of tissue hypoxia which occurs during an MI?
T-wave Inversion ST-segment Elevation Pathologic Q-wave
Ethical Principles in Nursing: Beneficence
The duty to do good to others and to maintain a balance between benefits and harms; paternalism is an undesirable outcome of beneficence, in which the health care provider decides what is best for the client and encourages the client to act against his or her own choices
Ethical Principles in Nursing: Fidelity
The duty to do what one has promised
Ethical Principles in Nursing: Justice
The equitable distribution of potential benefits and tasks determining the order in which clients should be cared for; being fair and equal to all
How does a tonometer measure intraocular pressure (IOP)?
The tonometer will register the force required to indent or flatten the corneal apex.
Pork is a good source of:
Thiamine
Client is coming from the recovery room after an above-knee-amputation, what should be at the bedside as a priority?
Tourniquet
Fetal well-being is determined during a nonstress test by:
Two 15-beat accelerations that lasted for 15 seconds occurring within 20 minutes.
Cyclosporin (Sandimmune), client should not receive what, because they are immunosuppressed?
Vaccinations
10-year-old child's (School-Age-Child) statements about the concepts of death with grandmother
Views death as irreversible and final, but may still have difficulty understanding. - "Once you die you never come back." - "My grandmother's death has been hard to understand." - "My grandmother died because she was sick and nothing could make her better."
Lindane is prescribed for Scabies, but is contraindicated for children if...?
Younger than 2 years old
Actions a nurse should take for a Pulmonary Embolism?
• Assess BP • Start IV • Give O2 • Give Morphine • Bedrest with HOB slightly elevated • Heparin (NOT Coumadin)
Left-Sided Heart Failure S/S:
• Dyspnea • Tachycardia • Crackles • Orthopnea • Paroxysmal Nocturnal Dyspnea • Fatigue • Nonproductive cough and crackles • Hemoptysis • Point of maximal impulse displaced toward the left anterior axillary line • S3 and S4 heart sounds • Cool/Pale Skin
Hyperthyroidism S/S
• Exophthalmos • Conjunctival Redness • Flushed/Warm/Moist Skin • Systolic Murmur at the Left Sternal Border
Temporal Lobe controls:
• Hearing • Language • Comprehension • Storage and Recall Memory
Occipital Lobe controls:
• Interpreting Visual Stimuli
Parietal Lobe controls:
• Interprets and Integrates Sensations, including pain, temperature, and touch
Right-Sided Heart Failure S/S:
• Jugular Vein Distension • Hepatomegaly • RUQ pain
Meniere's Disease Diet:
• Low-Salt • ∅ Sugar • ∅ Caffeine • ∅ Monosodium Glutamate • ∅ Alcohol
Tuberculosis (TB) Early Signs and Symptoms
• Low-grade Fever • Weight Loss • Pallor • Chills • Night Sweats • Anorexia • Fatigue
Pursed-Lip Breathing Instructions
• Maximal expiration • Close mouth and breathe in through nose • Purse lips and breathe out slowly through the mouth • Spend twice the amount breathing out as it took breathing in • Use abdominal muscles to assist in pushing out air • DO NOT puff out cheeks • DO NOT hold the breath
Frontal Lobe controls:
• Personality • Judgment • Abstract Reasoning • Social Behavior • Language Expression • Movement
Tension Pneumothorax S/S
• ↓Cardiac Output • ↓BP • ↑HR • Tachypnea • Distended Jugular Veins • Tracheal deviation to the OPPOSITE side
Cardiovascular S/S of Hypocalcemia
• ↓HR • ↓Peripheral Pulses • ↓BP
Late Signs of Increased ICP
• ↓LOC • Cushing's Triad (↑systolic BP and Widened pulse pressure, ↓HR, and irregular respirations) • Fixed and Dilated Pupils • Papilledema - optic disc swelling • Posturing • Cheyne-Stokes Respirations • ↓Response to painful stimuli
