2NCLEX FORMAT Safe, Effective Care Environment Management of Care Safety and Infection ControlHealth Promotion and MaintenanceGrowth and Development Through the Life SpanPrevention and Early Detection of DiseasePsychosocial IntegrityCoping and AdaptationPsychosocial AdaptationPhysiological IntegrityBasic Care and ComfortPharmacological and Parenteral TherapiesReduction of Risk PotentialPhysiological Adaptation
31. During the acute phase of a cerebrovascular accident (CVA), the nurse should maintain the patient in which of the following positions?Semi-prone with the head of the bed elevated degrees.Lateral, with the head of the bed flat.Prone, with the head of the bed flat.Supine, with the head of the bed elevated degrees.Kaplan, 2005Answer: 4Goal is to decrease intracranial pressure & to maintain a patent airway
44. Hyperglycemic Hyperosmolar Nonketotic Coma Kaplan, 2005 2. A client comes to the ER with c/o n/v and abdominal pain. He has IDDM. Four days earlier, he reduced his insulin dose when flu sxs prevented him from eating. The nurse performs an assessment of the pt which reveals poor skin turgor, dry mucous membranes, and fruity breath odor. The nurse should be alert for which of the following problems?1. Hypoglycemia2. Viral Illness3. Ketoacidosis4. Hyperglycemic Hyperosmolar Nonketotic Coma Kaplan, 2005Answer is 3Ketoacidosis is consistent with the “fruity breath”
5A pt hospitalized with a gastric ulcer is scheduled for discharge A pt hospitalized with a gastric ulcer is scheduled for discharge. The nurse teaches the pt about an anti-ulcer diet. Which of the following statements, if made by the pt, would indicate that dietary teaching was successful?“I must eat bland foods to help my stomach heal.”“I can eat most foods, as long as they don’t bother my stomach.”“I cannot eat fruits and vegetables because they cause too much gas.”“I should eat a low-fiber diet to delay gastric emptying.” Kaplan, 2005Answer: 2
64. The nurse cares for a patient receiving full strength Ensure by tube feeding. The nurse knows that the MOST common complication of a tube feeding is:EdemaDiarrheaHypokalemiaVomitingKaplan, 2005Answer is 2Diarrhea is due to intolerance of the solution
75. A man is diagnosed with cancer of the larynx and comes to the hospital for a total laryngectomy. When admitting this patient, how should the nurse assess laryngeal nerve function?Assess the extent of neck edema.Check his ability to swallow.Observe for excessive droolingTap the side of his neck gently and observe for facial twitching.Kaplan, 2005Answer is 2You want to maintain a patent airway; A pt with a laryngectomy has an increased risk of aspiration
86. The nurse cares for a pt with a possible bowel obstruction 6. The nurse cares for a pt with a possible bowel obstruction. An NG tube is to be inserted. Before inserting the tube, the nurse explains the purpose to the pt. Which of the following explanations, if made by the nurse, is MOST accurate?“It empties the stomach of fluids and gas.”“It prevents spasms of the sphincter of Oddi.”“It prevents air from forming in the small and large intestine.”“It removes bile from the gall bladder.”Kaplan, 2005Answer is 1An NG tube decompresses the stomach by emptying fluids and/or gas; it is also used to administer meds & feedings
97. The nurse evaluates the care provided to a pt hospitalized for tx of adrenal crisis. Which of the following changes would indicate to the nurse that the pt is responding favorably to medical and ng tx?The pt’s urinary output has increased.The pt’s blood pressure has increased.The pt has lost weight.The pt’s peripheral edema has decreased.Kaplan, 2005Answer is 2During an adrenal crisis, or deficiency of NA+; the pt experiences: pale skin, hypotension, increased UOP, dehydration. If the crisis is corrected, the pt converts to the opposite: warm, moist skin; increased blood pressure, decreased UOP, s/s of good hydration.
108. The physician orders heparin for a pt 8. The physician orders heparin for a pt. In order to evaluate the effectiveness of the pt’s heparin therapy, the nurse should monitor which of the following lab values?Platelet countClotting timeBleeding timeProthrombin timeKaplan, 2005Answer is 2Clotting time is the same as PTT. Heparin you follow the PTT; Coumadin, you follow the PT
11Pain at the site of the catheter insertion. 9. A pt returns to his room following a cardiac catheterization. Which of the following assessments, if made by the nurse, would justify calling the physician?Pain at the site of the catheter insertion.Absence of a pulse distal to the catheter insertion site.Drainage on the dressing covering the catheter insertion site.Redness at the catheter insertion site.Kaplan, 2005Answer is 2You must assess for lack of circulation to the lower extremity, possibly due to a clot.
12The nurse is caring for a pt with a cast on the left leg The nurse is caring for a pt with a cast on the left leg. The nurse would be MOST concerned if which of the following were observed?1. Capillary refill time was less than 3 secondsPt complained of discomfort and itching.Pt complained of tightness and pain.Pt’s foot is elevated on a pillow.Kaplan, 2005Answer is 3.Tightness and pain may indicate a pressure ulcer developing which can lead to infection or necrosis
1311. The home care nurse is visiting a client with a dx of hepatitis of unknown etiology. The nurse knows that teaching has been successful if the pt makes which one of the following statements?“I am so sad that I am not able to hold my baby.”“I will eat after my family eats.”“I will make sure that my children don’t eat or drink after me.”“I’m glad that I don’t have to get help taking care of my children.” Kaplan, 2005Answer is 3Hepatitis A is transmitted by oral/ fecal route;Hepatitis B is transmitted by blood/ body fluidsHepatitis C is transmitted by blood transfusions, blood/ body fluids
1412. The nurse is caring for a pt four hours after intracranial surgery 12. The nurse is caring for a pt four hours after intracranial surgery. Which of the following actions should the nurse take immediately?Turn, cough and deep breathe the pt.Place the pt with the neck flexed and head turned to the side.Perform passive range of motion exercises.Move client to the head of the be using a turning sheet.Kaplan, 2005Answer is 4Your goal is to decrease intrcranial pressure
1513. The nurse is caring for a pt with an acute myocardial infarction 13. The nurse is caring for a pt with an acute myocardial infarction. Which of the following laboratory findings would MOST concern the nurse?Erythrocyte sedimentation rate (ESR): 10mm/hHematocrit (Hct): 42%Creatine Kinase (CK): 150U/mLSerum Glucose: 100mg/ dLKaplan, 2005Answer is 3Cardiac Enzymes are monitored sequentially following a suspected MI. They include: CK, CKMB, Isoenzymes
1614. The nurse is supervising care of a pt receiving TPN through a single-lumen percutaneous central catheter. The nurse would be MOST concerned if which of the following was observed?The pt receives insulin through the single-lumenA mask is worn when changing the pt’s dressing.The pt’s dressing is changed daily using sterile technique.The pt is weighed two or three times per week.Kaplan, 2005Answer is 3You would change the dressing 3x per week; daily increases risk of infection. Insulin & TPN are compatible
1715. The nurse assists the physician with the removal of a chest tube 15. The nurse assists the physician with the removal of a chest tube. Before the physician removes the chest tube, which instruction should the nurse give to the pt?“Exhale and bear down.”“Hold your breath for five seconds.”“Inhale and exhale rapidly.”“Cough as hard as you can.”Kaplan, 2005Answer is 1You want to avoid the entry of air into the lung, which would occur with all of the other choices.
18Increase cardiac contractility and cardiac output. A man is admitted to the Telemetry Unit for evaluation of c/o chest pain. Eight hours after admission, the pt goes into ventricular fibrillation. The physician defibrillates the pt. The nurse understands that the purpose of defibrillation is to:Increase cardiac contractility and cardiac output.Cause asystole so the normal pacemaker can recapture.Reduce cardiac ischemia and acidosis.Provide energy for depleted myocardial cells.Kaplan, 2005Answer is 2Allowing asystole to occur enables the SA node to “kick in” and restart the heart rhythm again; hopefully in a normal pattern
1917. A pt newly diagnosed with Alzheimer’s disease is admitted to the unit. Which action, if taken by the nurse, is BEST?Place the pt in a private room away from the nurses’ station.Ask the family to wait in the waiting room while the nurse admits the pt.Assign a different nurse daily to care for the pt.Ask the pt to state today’s date.Kaplan, 2005Answer is 4You are assessing for pts orientation status; keeping the pt around others is good, particularly those they are familiar with.
2018. The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?Macaroni and cheeseShrimp with riceTurkey breastSpaghettiAnswer is 3
2119. The client with Alzheimer's disease is being assisted with activities of daily living when the nurse notes that the client uses her toothbrush to brush her hair. The nurse is aware that the client is exhibiting:AgnosiaApraxiaAnomiaAphasiaAnswer is 1
22The nurse knows that a positive diagnosis for HIV infection is made based on: Positive ELISA and Western blot tests.A history of high-risk sexual behaviorsEvidence of extreme wt loss and high fever.Identification of an associated opportunistic infection.Mosby, 2004Answer is 1
2321. A client with a family hx of atherosclerosis is advised to follow a diet based on the US Dept of Ag. Food Guide Pyramid. The nurse should teach the client to eat:4-6 servings of fruit daily5-7 servings of vegetables daily3-5 servings of meat, poultry, or fish daily6-11 servings of bread, rice or pasta daily.Mosby, 2004Answer is 4Note that the food pyramid has changed, and has added the “fats” portion.
2522. The teaching plan for a client receiving digoxin for left ventricular failure should include having the client:Sleep flat in bedRest during the dayFollow a low potassium dietTake the pulse three times dailyMosby, 2004Answer is 2You want to preserve your pts energy level by promoting rest; You would check the Apical Pulse, but only daily is needed b/c this med is administered daily.
26Severe radiating abdominal pain Cyanosis and symptoms of shock 23. During a routine physical exam, an abdominal aortic aneurysm is diagnosed. The client is immediately admitted to the hospital, and surgery is scheduled for the next morning. When performing the admission assessment, the nurse should expect:Severe radiating abdominal painCyanosis and symptoms of shockA pattern of visible peristaltic wavesA palpable pulsating abdominal massMosby, 2004Answer is 4All of the other choices may be the result of other conditions; An abd. Aortic aneurysm is associated with a pulsating abd mass
27Answer: ________________ A client has recently been diagnosed with Type I diabetes. A glucose tolerance test is ordered. The order reads, “Administer glucose 1.0 g/kg.” The client weighs 240 pounds. The nurse should administer: ( ___ pounds= 1 kg)There are 2.2 pounds per kg. Therefore the answer is 109 grams.Answer: ________________Mosby, 2004
2825. A female client has a tentative diagnosis of Cushing’s syndrome 25. A female client has a tentative diagnosis of Cushing’s syndrome. The nurse’s physical assessment of this client will probably include the findings of:Fever and tachycardiaLethargy and constipationHypertension and moon-faceHyperactivity and exopthalmosMosby, 2004Answer is 3Cushing’s Classic Symptom is the “Moon face” Choices 1,2,4 are all associated with Thyroid Disorders.
2926. The lab findings of a 40 yo man with burns are: BUN, 30mg/dL; serum potassium, 6.3mEq/L; pH, 7.1; PO2, 90mm Hg; and Hgb, 7.4 g/dL. The nurse is aware that these findings indicate:AzotemiaHypokalemiaMetabolic AlkalosisRespiratory AlkalosisMosby, 2004Answer is 1Azotemia results from excessive Nitrogen in Blood (BUN measures this)
3127. When teaching a client how to avoid dumping syndrome following a gastrectomy, the nurse should emphasize:Increasing activity after eatingAvoiding excess fluids with mealsEating heavy meals to delay emptyingProviding carbohydrates with each meal Mosby, 2004Answer is 2You want to avoid fluids b/c they increase emptying which can cause increased symptoms with Dumping Syndrome
3228. The nurse is preparing to change a client’s dressing 28. The nurse is preparing to change a client’s dressing. The statement that best explains the basis of surgical asepsis that the nurse will perform in this procedure is:Keep the area free of microorganismsProtect self from microorganisms to the surgical siteConfine the microorganisms to the surgical siteKeep the number of opportunistic microorganisms to a minimumMosby, 2004Answer is 1
33By seeding across membranes of body tissues 29. A 30 yo female dancer notices a mole on her ankle has turned dark brown and seeks medical attention. A diagnosis of malignant melanoma is made. This client has increased her chance of survival by early tx, b/c melanoma spreads quickly. The nurse recognizes that melanoma spreads:By seeding across membranes of body tissuesBy runner-like chains of cells to satellite tumorsThrough invasion of the lymphatic system and bloodstreamThrough direct extension into subcutaneous tissue to boneMosby, 2004Answer is 3Cancers tend to spread/ metastisize to areas near their original site; with Melanoma being on the skin, it easily gets into the bloodstream & lymphatics.
3530. A client with burns develops a wound infection 30. A client with burns develops a wound infection. The nurse knows that local wound infections are primarily treated with:Oral antibioticsTopical antibioticsIV antibioticsIM antibioticsMosby, 2004Answer is 2With local infections, you treat them topically; Silvadene Cream is commonly used to treat burns.
36A client is admitted to the hospital after sustaining a head injury A client is admitted to the hospital after sustaining a head injury. The most reliable sign that this is client is experiencing an increase in intracranial pressure would be a slowly:Rising RRNarrowing pulse pressureDecrease in level of consciousIncreasing diastolic blood pressureMosby, 2004Answer is 3
3732. A client has been admitted to the emergency department with multiple injuries including fractured ribs. Because of the client’s fractured ribs, the nurse should assess for signs of:PneumonitisHematemesisPulmonary EdemaRespiratory acidosisMosby, 2004Answer is 4.Pain causes rapid , shallow breathes which causes CO2 retention; this in turn leads to acidosis
3833. A client is placed on a ventilator 33. A client is placed on a ventilator. Because hyperventilation can occur when mechanical ventilation is used, the nurse should monitor the client for signs of:HypoxiaHypercapniaMetabolic AcidosisRespiratory AlkalosisMosby, 2004Answer is 4Hyperventilation leads to loss of CO2 which leads to increased pH, and subsequently alkalosis
3934. A 21yo client comes to the ED with chief complaint of left sided chest pain following racquetball game. A chest x-ray reveals a left pneumothorax. When assessing the left side of the client’s chest, the nurse would expect to find:A dull sound on percussionVocal fremitus on palpationRales and rhonchi on auscultationAn absence of breath sounds on auscultationMosby, 2004Answer is 4You hear absent breath sounds with a pneumothorax.
40____Pruritus ____Oliguria __x__Tachycardia __x__Cloudy Outflow 35. A client with end-stage renal dz is receiving continous ambulatory peritoneal dialysis. The nurse is preparing to teach the client to monitor for signs of complications associated with peritoneal dialysis. Check all the complications that should be included in this teaching plan.____Pruritus____Oliguria__x__Tachycardia__x__Cloudy Outflow__x_Abdominal PainMosby, 2004The first two are the result of early renal failure, not end-stage.
4136. A client with a distal femoral fracture is placed in skeletal traction. The nurse is aware that the weights would only be removed if:There is a life-threatening situationThe client complains of intense painThere is evidence of external rotationThe cords have become twisted during turningMosby, 2004Answer is 1You never remove wts from traction unless in an emergency situation, such as cardiac arrest.