Practice Test 2023: NCLEX-PN Flashcards
(162 cards)
1
Q
Gunshot victim transported to ED via EMS. Needs emergency surgery no next of kin present.
What is the proper way to obtain informed consent
A
No informed consent is needed when life saving procedures are necessary to save a life
2
Q
Which of the following describes Assessment
Data collection and validation
Direct care
Goal setting
Evaluation
A
Data collection and validation
3
Q
Diagnosis is the 2nd step of the nursing process.
Which describes diagnosis
Planning and implementation
Evaluation
Data collection and validation
Goal setting
A
Planning and implementation
4
Q
Which of the following is not part of the Self-actualization part of Maslows Hierarchy of needs
Spiritual growth
POV of others
Reaching Max Potential
Acceptance
A
Acceptance
Acceptance is part of the Self-esteem
Empowering Environment is also part of Self-actualization
5
Q
Nurse is friends with a patient
After discharge the nurse hasn’t heard from the patient.
Nurse post on patient’s social media
Hey girl, haven’t heard from you since you left the hospital
What has the Nurse done
Broken the law
Written unethical statement
Dismissive of patients feelings
Nothing wrong
A
Broken the law
HIPPA
6
Q
Which would you as an RN not assign to a new LPN
Assisting a post op patient 12 hours out of surgery with going to the rest room
Feeding a patient with early Alzheimer’s
Teaching a family about ambulating for the first time
Foley care
A
Teaching family about ambulation for the first time
RN should be first nurse to assess and teach a patient about ambulation after surgery
7
Q
Nurse suspects patient is having a seizure in L&D unit. What is the most important intervention
Place patient of left side
Call code blue
Give patient magnesium
Check poc glucose on the patient
A
Place on left side to prevent aspiration
Call RAPID RESPONSE rather than code blue
8
Q
Allopurinol 200mg
What is it prescribed for?
Precautions
A
Antigout Agent: Lowers uric acid
(Uric acid forms when Purines breakdown found in foods: Small canned fishes, beer, dried beans)
Drink 8 glasses of water daily
9
Q
After Salem Sump NG tube
Client vomits moderate amount.
What is the most appropriate action to take?
A
Irrigate with 20mL NS
10
Q
Priority action for a client who is a daily alcohol abuser.
- Reorient client to the environment frequently
- Maintain in a cool, darkened room
- Assist the client drinks more isotonic fluids
- Administer thiamine 100mg IM
A
- Reorient client to the environment frequently
Safety
Client may hallucinate and reoriention will maintain Safety
11
Q
isoniazid (Antibiotic)
part of the cocktail for TB
Thus serious side effect
A
Liver injury
12
Q
What is uneven skin pigmentation in the elderly associated with.
A
Normal finding
Skin becomes more avascular
Prone to pallor.
Long-term sun exposure produces white or gray Macules
Lentigines (commonly referred to as “liver spots”
13
Q
Which of the following demonstrates understanding
Client prescribed clopidogrel 75mg
- I will have my blood tested regularly
- I will need to stop taking garlic tablets that I take for my cholesterol
- I can continue taking my Ibuprofen
- I will make sure to take a multi vitamin from now on
A
- I will need to stop taking garlic tablets that I take for my cholesterol
Garlic also inhibits platelets
14
Q
Which finding at a fasting blood glucose Indicates gestational diabetes
40
100
140
180
A
180
140 is the maxium normal number
15
Q
Phenytoin antiseizure medication
Major side effects
Speech: Slurred / Rapid
Energy: Hyper / lethargic
Coma / seizures
A
Slurred speech
Lethargy
Seizures
Spinning sensation
Nystagmus (Rapid eye movements)
16
Q
Sertraline (Zolfot) SSRI
How long does it take to work
Common SE
A
4 weeks
SE
Nausea
Inability to sleep
Dry mouth
Decreased libido
17
Q
Maslows hierarchy of needs
Bottom first / Most fundamental
A
Physiological
Safety / Security
Love and Belonging
Self-esteem
Self-Actualization
18
Q
Applying Maslows Hierarchy
- Recognize Physical or Psychosocial
- Eliminate Psychosocial (Pain is Psychosocial)
- Does this make sense to the disease process
- Apply ABCs
Arrive at correct answer
A
Yeppers
19
Q
Applying Maslows
Ruptured ectopic pregnancy/ laparotomy is scheduled
Most important for Plan of Care
- Fluid replacement
- Therapeutic communication
- Emotional support
- Oxygen therapy
A
- Fluid replacement
Eliminate 2&3 (Psychosocial)
Eliminate 4. Oxygen doesn’t make sense in the question. There is no mention of low oxygen levels nor is it to be expected
20
Q
Applying Maslows
Anorexic girl 82 lbs & 5’ 4”
Labs: Hypokalemia, anemia, dehydration
Which has the highest priority
- Body image disturbance related to weight loss
- Self-esteem disturbance related to weight loss
- Impaired nutrition: Less than the body requirement
- Deficient cardiac output related to the potential for Dysrhthmias
A
- Deficient cardiac output related to the potential for Dysrhthmias
Eliminate 1 & 2 Psychosocial
Between 3 & 4 which one involves the ABCs, Keep number 4
21
Q
On NCLEX you should assume you have an order for all “Dependent” nursing actions.
Ie. Giving a pill, orders, oxygen
T or F
A
T
22
Q
Does “Assessment” always come before “Intervention”
A
Yes
Unless the question is looking for an intervention, due to the assessment already being done
23
Q
6 hr post op ab surgery
Nursing Processs ADPIE
Most important action
- Have client use pillows to splint incision
- Instruct client how to safely get out of bed
- Reinforce dry dressing to provide more padding
- Turn client to check for bleeding underneath client.
A
- Turn client to check for bleeding underneath client.
Assess first, then intervention
24
Q
ADPIE / ABC
child fell riding bike and has a possible fractured right Femur. Severe pain, conscious and alert
Which is the first action taken.
- Immobilize limb with splint and ask client not to move
- Collect data of the circumstances of the fall
- Place in semi-fowlers posistion to facilitate breathing.
- Check pedal pulse / blanching both legs and compare findings
A
- Immobilize limb with splint and ask client not to move
The question states “possible fracture”. Hence, the assessment was already done.
Eliminate 2 & 4 Assessments
Eliminate 3. There is nothing in the question that states breathing problems.
Just because ABC are one of the answers doesn’t mean you have to chose it.
Does the ABC make sense? In this case No
25
ADPIE
A child biking to school fell of bike. The child tells the nurse: I think I broke my leg.
What is the first action taken
1. Immobilize affected leg with splint and instruct client not to move.
2. Collect data of the circumstances surrounding the fall
3. Place in semi-fowlers posistion to facilitate breathing
4. Check appearance of leg
4. Check appearance of leg
Determine if Assessment or Interventions is needed
Assessment comes first always
Eliminate 1 & 3 Interventions
Priority: Examination of leg is more urgent than the background story
26
Safety Strategy - Flow sheet
All possible answers are Interventions
Try to answer based on knowledge, if unable
What will cause the client the least amount of harm
Correct Answer
Imagine being an RN at MVH
Overnight and chilling
40$ ph, pension, vacation, sick days
27
Safety
Pediatric tonsillectomy/ unresponsive to antibiotics. After surgery child brought to clinical unit.
What action should be included in the plan of care?
1. Institute measures to minimize crying
2. Perform postural drainage q2h
3. Cough & deep breathing hourly
4. Provide ice-cream as tolerated
1. Institute measures to minimize crying
Safety
1. All answers are interventions
2. Try to answer using your Knowledge
3. What will cause my client the least amount of harm
(2.) Postural drainage can cause bleeding
(3.) Can cause bleeding
(4.) May cause child to clear throat and cause bleeding
The nurse must prevent postop hemorrhage.
1. Crying may irritate throat and increase chance of bleeding
28
Safety
Nurse doubts accuracy on MAR.
What action should they take first?
1. Compare MAR with order in medical record
2. Contact prescribing HCP
3. Consult pharmacy
4. Compare information about meds in a nursing book.
1. Compare MAR with order in medical record
The nurse needs to know what the original order said.
29
Safety
Wrist restraints to dementia client
Which action is most appropriate
1. Attach ties of restraints to bed frame
2. Perform daily ROM to restrained extremities
3. Remove restraints when in a wheelchair
4. Explain restraints need to family only
1. Attach restraints to bed psot.
ROM exercises need to be more frequent than daily. q4h
Only remove when supervised
Explain need to the client too
30
Priority
Bipolar stopped taking Lithium
No food or sleep for 2 days.
Upon admission what nursing action has the highest priority
1 reinforcement of importance for taking Lithium
2. Provide with safe environment with few distractions
3. Arranging food and rest for client
4. Setting limits on behavior
Food and Rest
Maslows hierarchy
Eliminate Psychosocial 1 & 4
Ask self if others make sense
Both make sense
Food and rest and physiological
Safety is 2nd to physiological
31
Safety
NG tube at low intermittent suction for client with intestinal obstruction.
2 hrs after insertion client vomits. While irrigating NG tube resistance is felt
Which action should be taken first
1. Replace NG tube with larger one
2. Turn client onto left side
3. Implement continuous NG tube suction
4. Continue NG tube irrigation
2. Turn client to left side (Tip of tube maybe against stomach wall)
Steps:
1.All answers are Interventions = safety
2.Can you answer based on your knowledge
3. What will cause client least amount of harm?
1. Replacement with larger NG tube can damage mucosa
3. Continuous suction will erode mucosa
4. NEVER FORCE IRRIGATION
32
To answer Priority questions properly
Use these 3 strategies
Maslows, nursing process, safety (abcs - if it makes sense)
33
Assisting client with ambulation when they begin to fall.
Most appropriate action
1. Grasp client underarms and bend at the waist and assist client to the floor
2. Place feet close together, place arms under clients Axillary, slide client to the floor
3. Place arms around waist of client and assist to nearest chair or bed.
4. Place feet wide apart, push Pelvis forward, and slide the client down one leg.
4. Place feet wide apart, push Pelvis forward, and slide the client down one leg.
34
Clients radial pulse dropped from 72 to 56 bpm since last VS check 4 hrs ago.
Most important action for nurse
1. Check oxygen sat levels
2. Begin Ox at 2/L minute via NC
3. Obtain BP
4. Palpate bilateral pedal pulse strength
Obtain BP (Drop in HR = Drop in cardiac output = No blood to organs)
1. Ox Sat levels NOT dependent on cardiac output, affected by Altered Respiratory Function
2. More Assessment is needed before intervention
4. Bilateral pulse strength is important But not as important as Overall BP
35
Client states "I feel short of breath" has NS infusion of 75mL/hour through PICC line
First action taken
1. Obtain BP & apical HR
2. Reassure client that SOB will improve
3. Observe PICC insertion site
4. Elevate HOB to 90°
4. Elevate HOB to 90°
Intervention is needed because it's ABC.
Shortness of breath requires immediate action
36
Vaginal delivery result3d in a still born
Most important action by the nurse
1. Be available to the client to listen to expressions of grief
2. Provide client with appropriate fluid replacement.
3. Check client's perineal pad frequently for excessive bleeding
4. Tell client about measures to cope with severe uterine pain
3. Check client's perineal pad frequently for excessive bleeding
Maslows / ABC
Eliminate Psychosocial
No evidence of dehydration.
Evidence of blood loss due to giving birth (ABC)
37
Left or Right sided HF
Dyspnea, Orthopnea, frothy sputum, crackles, Pallor, fatigue, coolness, weak pulse, pulmonary edema.
Juglar vein distention, hepatomegaly, ascites, decreased bowel sounds, generalized edema
Left sided: Left Ventricle, unable to pump unoxygenated blood to body and Backs Up in the Lungs
Right sided HF
Right Ventricle unable to properly pump blood and results in BACKFLOW to Right Atrium & Venous Congestion
Dyspnea, Orthopnea, frothy sputum, crackles, Pallor, fatigue, coolness, weak pulse, pulmonary edema, Increased Creatinine & decreased urinary output due to poor renal perfusion
Juglar vein distention, hepatomegaly, ascites, decreased bowel sounds, generalized edema
38
2 most common causes of CKD
Chronic kidney disease
Hypertension & DM
39
Explain S&S of Hyperkalemia & Hypokalemia
As K goes so does the body except for Cardiac & Urine output
40
Which medication is used to treat Hyperkalemia
1. Spironolactone
2. Prednisone
3. Naproxen
4. Sodium polystyrene
4. Sodium polystyrene (Replaces the K for Na in the GI tracts)
Spironolactone is a K sparing diuretic
Corticosteroids (Prednisone) lead to K retention
NSAIDS like Naproxen Increase K by Decreasing kidney ability to excrete K
41
Hyperkalemia
Which nursing actions are indicated
1. Cardiac Monitor
2. IV reg insulin & Dextrose 5%
3. Maintain strict bed rest
4. Anti seizure precautions
5. Loop diuretics
6. Monitor I& O
1. Cardiac Monitor
2. IV reg insulin & Dextrose 5%
5. Loop diuretics
6. Monitor I& O
Not indicated
Hyperkalemia doesn't cause Seizures
42
Provide care to stable clients
Provide care to unstable clients
RN / LPN
Stable LPN
Unstable RN
43
Initiate oxygen treatments
Collect data and lab specimens
Monitor Is & Os
Blood Glucose
Apply dressings
Initial assessment
Give teachings and discharge
Insert & care for catheter & ng tube
Pass medication
Empty JP drains
Which are duties of LPN
Collect data and lab specimens
Monitor Is & Os
Blood Glucose
Apply dressings
Insert & care for catheter & ng tube
Pass medication
Empty JP drains
LPN may also
Maintenance of Oxygen delivery
Reinforce teachings
RN
Initial assessment
44
What roles does an LPN have in blood Transfusions / IVs
Monitor IV site / Blood Transfusion after first 15 minutes
Hang or change bag IV fluid to existing line
Admin IV piggyback meds
Discontinue peripheral IV
Preform site care
45
An RN my assign a LPN to assess a client to help with making nursing judgments.
T or F
F
Assessment, Evaluation, & nursing judgments may not be assigned to LPNs
46
Most appropriate for an LPN
1. Obtain VS for a newly admitted client with several fractures
2. Monitor client client who had an Ovarian tumor removed 2 days ago
3. Teach recently diagnosed DM client how to perform insulin injection
4. Bathe and change clothes of client recovering for appendectomy
2. Monitor client client who had an Ovarian tumor removed 2 days ago
1. Obtain VS for a newly admitted client with several fractures (RN -Unstable)
3. Teach recently diagnosed DM client how to perform insulin injection (RN- new teaching)
4. Bathe and change clothes of client recovering for appendectomy (UAP)
47
Best assignment for LPN
1. Help client recovering from surgery with bathing, linen change, and ambulation to bathroom
2. Perform Head-to-toe assessment for client admitted yesterday with pneumonia
3. Assess newly admitted client with high fever and productive cough
4. Change dressings for a statis ulcer in a client with DM.
4. Change dressings for a statis ulcer in a client with DM.
1. Help client recovering from surgery with bathing, linen change, and ambulation to bathroom (UAP)
2. Perform Head-to-toe assessment for client admitted yesterday with pneumonia (RN)
3. Assess newly admitted client with high fever and productive cough (RN)
48
Client care should be assigned to LPN
1. Assess new admit with severe ab pain
2. Review education on birthing methods provided to a pregant client
3. Provide bedside care for infant client with fever and discomfort
4. Change dressings of a client who underwent partial mastectomy
4. Change dressings of a client who underwent partial mastectomy
RN responsibility other actives
2. Review education on birthing methods provided to a pregant client
A LPN may reinforce teaching but not evaluate them
49
Can a LPN educate about preprocedure instructions
Yes ?
50
LPN is floating to several units in the hospital. Which client-care activity is best for LPN
1. Assist postsurgical client with ambulation to bathroom
2. Checking with family members about effectiveness of discharge teachings.
3. Instruct newly admitted client about diagnostic test preparation
4. Changing the Purulent dressing of a client with stage 4 pressure injury
3. Instruct newly admitted client about diagnostic test preparation
LPNs are trained to provide client education and physical preparation for diagnostic test.
4. LPNs can change dressings but stage 4 is considered unstable
51
Can LPNs administer IV push medications
No
52
Can UAP fill out incident reports
Yes, if they witness the incident
53
When to use Hot / Cold therapy
Hot = chronic pain / muscle pain (Will bring more blood to the area Vasodilation)
Cold = Acute pain. (Will Vasoconstrict and lessen blood to area)
54
Strategy for Posistioning
1. Are you trying to prevent or promote?
2. What are you trying to prevent or promote?
3. Think A&P
Correct answer
Become a NP by 47
55
Immediately after percutaneous liver biopsy, client should be placed in which posistion?
1. Supine
2. Right side-laying
3. Left side-laying
4. Semi-fowlers
2. Right side-laying
Why?
After surgery what is the biggest risk?
Hemorrhage
To prevent Hemorrhage do we Apply or Not Apply pressure?
Apply Pressure
Where is the liver located?
Right side
Correct answer will Apply pressure to the right side-where the liver is located
56
Client gets angiogram for decreased circulation in right leg. After the angiogram what posistion should the client be put it?
1. Semi-fowlers with right leg bent at the knee
2. Side-laying with a pillow between the legs
3. Supine with right leg extended
4. High fowler with right leg elevated
3. Supine with right leg extended
Think about it
Promotion or Prevention? Promotion of blood to right leg
What promotes blood flow to right leg?
Keeping right leg at or Below heart level
57
How to turn a client after a laminectomy?
1. HOB 30°, client locks knees when turning
2. Pillow placed between legs, body turned as a unit.
3. Client straightens back and grasps side rails on opposite side of the bed
4. HOB flat, client bends knees and rolls to the side.
2. Pillow placed between legs, and body rolled as a unit.
Why?
Prevention or Promotion:
Promotion of a straight back
(After Lamenectomy client must not bend or twist torso)
Log Rolling = name of maneuver
58
Client continues to report pain after appendectomy despite analgesics.
Which measure is most appropriate
1. Notify HCP
2. Place in semi-fowlers posistion
3. Massage abdomen
4. Guided meditation
2. Place in semi-fowlers posistion
Notifying HCP is almost never correct
59
Describe
Dorsal recumbent posistion
Supine with knees flexed; more comfortable
60
Describe Use of Side Lateral posistion
Allows drainage of oral secretion
61
Describe use of Sims posistion
Allows drainage of oral secretions and Rectal Exams
62
HOB elevated Various Fowlers
Describe (2) general uses
Increases venous return
Allows maxium Lung Expansion
63
Feet & legs elevated has this affect
Increases blood return to the heart
64
Feet elevated and head lowered (Trendelenburg)
2 uses
Insert Central Venous Pressure Line CVP
Umbilical Cord compression
65
Feet elevated 20°
Knees straight
Trunk Flat
Head slightly elevated
(Modified Trendelenburg)
2 uses
Increase Venous Return
Prevent Shock
66
Elevation or Deelevation of extremity
Increases Venous Return & decreases blood volume to extremity
Elevated
67
Lithotomy posistion is
Flat on back, thighs flexed, legs abducted
Used for...
Increases vaginal opening for exam
68
Prone posistion is Contradicted for people with this problem
Respiratory or Cardiovascular
69
Knee to chest posistion is used for..
Maximal visualization of rectal area
70
Client 6 months ago had a T6 spinal cord injury. Client reports Throbbing headache, face-chest-neck all red and diaphoretic
What is the first action
1. Loosen clients upper body clothing
2. Check fir fecal impaction
3. Remove indwelling catheter
4. Sit client in an upright posistion
4. Sit client in an upright posistion
Client has Autonomic Dysreflexia (complication of >T6 spinal cord injury) EMERGENCY
All answers are correct but the First thing to do is sit up to reduce blood pressure
71
Client diagnosed with right-sided stroke 2 weeks ago. When assisting with meals what is the most important
1. Encourage swallow 4x
2. Assist client to use straw to drink fluids with meal
3. Instruct client to sit in chair 30 minutes after meal
4. Provide 8oz milk with every meal
3. Instruct client to sit in chair 30 minutes after meal
This question is asking about ASPIRATION PREVENTION.
Sitting for 30 minutes will help ensure food travles to the stomach
swallowing 4x is not needed
Straws and thin liquids are ASPIRATION risks
Milk makes excessive saliva, ASPIRATION risk
72
Which requires intervention 48 hrs after right total hip arthroplasty
1. Client is positioned high fowler during meal time
2. Right & left legs are slightly abducted when client is supine
3. HOB is 50° during morning oral care
4. UAP places pillow between clients legs before turning the client
1. Client is positioned high fowler during meal time
What is a big risk 48 hrs after total hip replacement? Subluxation (partial dislocation of hip)
1. Elevation HOB >60 increases risk of dislocation
2. Slight abduction decreases risk of dislocation
3. HOB <60° Is not risk for dislocation
4. Pillow between legs maintains slight abduction- correct
73
What is the correct way for a client to pull them selves up from a sitting position using their walker?
None. Don't use a walker to pull yourself up
Use arms of the chair, grab bars, or a counter.
A WALKER WILL TIP OVER
74
Proper technique to go up stairs with a walker?
Down stairs?
Don't use a walker on stairs
Have someone carry walker up stairs and use the hand rails
75
Osteoarthritis is a condition that involves loss of...
Cartilage in synovial joints
76
PAD is narrowing of upper and lower arteries caused by....
Clinical findings include
Atherosclerosis ( build-up of fats, cholesterol, on artery walls )
Claudication (ischemic muscle pain that occurs with exercise)
77
Hyperlipidemia is a major risk factor for...
CAD
Coronary artery disease
78
Lordosis causes....
an unusually large, inward arch on the lower back, just above the buttocks. The condition may cause lower back pain.
79
Psych Unit
Client asks " Am I in a special radioactive shelter? When was it last checked for radioactivity?"
Which response is most appropriate?
1. This is a hospital, and we don't have a nuclear medicine dept here.
2. Don't worry your safe. There's no radioactivity here
3. I'm sure your safety is of concern to you, but this is a hospital
4. Please share with me what makes you think there is radioactivity here.
3. I'm sure your safety is of concern to you, but this is a hospital
In psych patients. Look for answers that reflect feelings and gives information
80
Under most circumstances which treatment from the clients care plan will be provided first to a hospice patient
1. Administer acetaminophen 650 mg rectal suppository
2. Administer 0.5 mL oral liquid morphine 20mg/ mL
3. Provide mouth care with oral sponge and water
4. Change diapers and perineal care
2. Administer 0.5 mL oral liquid morphine 20mg/ mL
Managing pain is normally the priority in hospice
81
Describe skin when patient is near death
Molted- different color patches
82
Which 2 findings indicate the client has expired
1. No movement or breathing
2. Unresponsive
3. Cool Mottled skin
4. Absence of apical pulse
5. Absence of audible BP
6. Dilated pupils
1. No movement or breathing
4. Absence of apical pulse
Not
Cool Mottled Grey skin can be present in the hours leading up to death
NonAudible BP maybe present several hours B4 death
83
Most important question for a patient with OCD?
1. Do you find yourself forgetting simple things
2. Do you find it difficult to focus on a given task?
3. Do you have trouble controlling upsetting thoughts
4. Do you experience panic in a closed in area?
3. Do you have trouble controlling upsetting thoughts. (OCD has trouble controlling intrusive, repeating thoughts)
1. Do you find yourself forgetting simple things (Cognitive Disorder)
2. Do you find it difficult to focus on a given task? (Depression)
4. Do you experience panic in a closed in area? (Panic disorder)
84
Seizure client states I hear drums
What does the nurse do first?
1. Tell them to ignore it
2. Place in a darkroom away from nurses station
3. Ask followup questions
4. Insert oral airway
4. Insert oral airway- Prevents biting tongue during seizure
Before a seizure or migraine clients experience: Auras are partial or focal seizures that sometimes happen before a more severe seize occurs (characterized by brief sensory alterations)
85
Which type of lung sound need follow up
Vesicular or Adventitious
Adventitious
86
Pale, Cool, Sweaty skin
Slurred speech
Liable
HR 124
Thirsty
Urine often
Hungry
Dry mouth
Blurred vision
Hypoglycemia/ Hyperglycemia
Pale, Cool, Sweaty skin
Slurred speech
Liable
HR 124
Hypoglycemia
Thirsty
Urine often
Hungry
Dry mouth
Blurred vision
Hyperglycemia
87
Why do patients get Tachycardia & Diaphoresis with Hypoglycemia?
Why do they have confusion, difficulty speaking, and stupor?
Tachycardia & Diaphoresis due to release of Epinephrine
Confusion, difficulty speaking, and stupor- Lack of glucose to brain
88
Hypoglycemia <70 may cause this complication
1. Osmotic diuresis
2. Hypokalemia
3. Hypovolemia
4. Seizures
4. Seizures
Lack of glucose in the brain leads to significant impairment
89
Blood Glucose <60 Alert & Verbal
1st thing
2nd thing
Possibel 3rd thing
Give 15 G fast acting carb
Wait 15 minutes & Chexk BS
If <70 give 15 g fast acting carb
90
Client receiving Paroxetine
Most important information to tell HCP
1. Appetite change
2. Recently started in Digoxin
3. Applys sunscreen when going outside
4. Drives car to work
2. Recently started in Digoxin
Paroxetine (SSRI) can decrease ability of Digoxin to work (slow your heart rate down and improve the filling of your ventricles. Improves A fib )
1. Weight loss is to be monitored with SSRI
3. Sunscreen is needed Prevent photosensitivity SSRI SE
4. Driving is allowed after determining response to Paroxetine
91
DRN order. Which is the 1st action taken
1. Administer life saving medicine
2. Assess client for signs of death
3. Open airway and give 2 breaths
4. Summon emergency code team
2. Assess for signs of death
No life saving measures given Including medication
92
LPN is working in newborn nursery
Which assignment should they question
1. 2 day old laying quietly alert with HR 185 BPM
2. 1 Day old crying with bulging fontanel
3. 12 hr old RR 45 and irregular while crying
4. 5 hr old Hands & Feet blue bilaterally when sleeping
1. 2 day old laying quietly alert with HR 185 BPM
Tachycardia Resting normal = 120 - 160 BPM. LPN only care for stable
Bulging fontanel are normal when crying
Normal RR is 30 - 60 newborns
Acrocyanosis is normal 2 - 6 hrs after delivery due to poor peripheral circulation
93
Infection that spread to the bloodstream and impact perfusion is aka...
Sepsis
94
Type of fluid that will expand intravascular volume. Needed to Raise BP in sepsis
Isotonic
NS .9
LR
95
D5W
.45,.35,.225 NS
Type of solution (Hypo, Isotonic, Hyper)
Biological function
Hypotonic
Expand cell
D5W Isotonic in bag, Hypotonic in the body.
96
DKA & HHNS (Hyperosmolar hyperglycemic nonketotic syndrom)
Both get this type of fluid, why
Hypotonic
It puts fluid back into the cells
97
Don't give this type of fluid with ICP Increases Cranial Press, Burn, or Trauma
Hypotonic.
Makes cells swell even more
98
When administering a (hypotonic / hypertonic) solution, a nurse should closely watch for signs of hypervolemia:
Elvated blood pressure and breathing difficulties.
(Hypotonic /Hypertonic) solutions move fluid from the intracellular and interstitial spaces to the extracellular compartment, which increases the risk of hypervolemia
Hypertonic
99
When giving a hypotonic solution beware of these possible complications
hypovolemia, hypotension, or confusion
Cellular edema
Hyponatremia
100
One hour management of Sepsis includes
Measure _____ . Why?
Obtain Blood cultures. Why?
Admin broad spectrum antibiotics
Rapidly infuse crystlloid fluids
Which do you do first? Why?
Measure Serum lactate
(tissue perfusion, detect shock, and adjust therapy. Elevated lactate levels = severe hypoperfusion)
Blood cultures are used to determine type of bacteria, what antibiotics it is susceptible to
First, blood draw. Determine type of bacteria Before Broad spectrum antibiotics Interfer with test
101
Is inserting NG tube a sterile procedure?
No, clean procedure Not sterile
Because digestive track will kill germs
102
Which statement needs more education from a hep B patient
1. I must not let family share my silverware
2. I must not let my family share my towels
3. I'm looking forward to enjoying intercourse with my spouse when I return home.
4. I must eat small frequent meals
3. I'm looking forward to enjoying intercourse with my spouse when I return home.
Hep B can live outside the body for atleast 7 days. Any surface with blood or body fluid can transmit HepB
103
1 day old diagnosed with Intrauterine growth retardation, high pitched shrill cry, restless, and irritable with fist sucking behaviors.
What should the LPN do first
1. Gently massage the clients back q2h
2. Tightly swaddle client in flexed posistion.
3. Schedule feedings q3-4h
4. Encourage eye contact during feedings
Describe nursing interventions
2. Tightly swaddle client in flexed posistion.
Classic symptoms of DRUG Withdrawal
Manifest 12 hrs - 10 days
Nursing interventions
Assess muscle tone, VS, IRRITABILITY
Admin phenobarbital
104
Pediculosis
S&S
Pertussis
Macules & Papules
Presence of nits
What is Pediculosis
Pediculosis= Lice
105
GYN clinic
Off white vanginal discharge with curd like appearance and vulvar itching.
What is most important question to ask?
What is the treatment?
What kind of birth control do you use? Oral contraceptives cause CANDIDIASIS
Treatment: topical clotrimazole, nystatin (Antifungal)
106
Elastic wrap bandage from toe to mid thigh.
What action should be taken?
1. Increase friction between skin & bandage
2. Leave small distal portion of extremity exposed
3. Use multiple pins to secure
4. Posistion leg in abduction
Why use an elastic bandage?
2. Leave small distal portion of extremity exposed
Determines color, motion, ans sensitivity of body.
Use elastic bandage:
Muscle sprains and strains
bone fractures
Benefits
Reduce swelling
Restrict blood flow
Decrease pain
Prevent further damage
Limit further damage
Allow continued activity
107
Post laparoscopic cholecystectomy client states: I hate the thought of eating low-fat diet for the rest of my life. Most appropriate response
1. I will ask the dietician to speak with you.
2. What do you think is so bad about a low-fat diet
3. It may not be necessary for you to follow a low-fat diet that long
4. Atleast you will be alive and not suffering
3. It may not be necessary for you to follow a low-fat diet that long
Fat restrictions is usually lifted with time. The bill billlary ducts swell to hold volume that was once in gallbladder
108
Stroke left-sided paralysis and homonymous hemianopia. Which action should be taken?
1. Provide morning care from the right side.
2. Speak loudly and clearly when talking
3. Reduce light level to reduce glare
4. Provide client care to reduce the clients energy expenditure
1. Provide morning care from the right side.
Homonymous hemianopia = blindness in each half of the vision field caused by brain damage.
Client must turn head side-to-side to scan field of vision
Approach from nonvisually impaired side. Left sided paralysis = Approach from the right
109
COPD patient is likely to have (Acidosis/ Alkalosis)
Acidosis
110
Type of exercises to be preformed with a cast
Isometric
Exp. straighten your leg in the air and hold it for 15 to 20 seconds
111
LRQ pain best intervention
1. Encourage slow,shallow rhymtic breathing
2. Massage to RLQ
3. Heating pad to RLQ
4. Posistion for comfort
4. Posistion for comfort
Slow, Deep, rhymtic breaths - not shallow
Massage & Heat pad can cause appendicitis- rupture of apendix
112
VS
Temp 103
Pulse 82
RR 14, shallow, unlabored
BP 134/88
CLIENT: 80 F
Why would you retake the temperature with a different thermometer?
Because other vital signs are normal
With a fever HR & RR will increase
113
Comatose bed bath
LPN will intervine if the following happens
1. UAP answers phone while wearing gloves
2. UAP log rolls client to preform back care
3. UAP places incontinence pad under client
4. UAP posistions client on left side, with HOB elevated
1. UAP answers phone while wearing gloves
(Solied gloves need to be removed & Hand Hygine practiced before answering phone)
4. UAP posistions client on left side, with HOB elevated - This is the correct posistion to prevent aspiration
114
Hip fracture
Affected leg is (Shortened/ Lengthened)
Rotated (Internally/ Externally)
Affected leg is shorter and externally rotated
115
Discharge patient from inpatient alcohol treatment.
Which statement by clients wife shows the family is coping adaptively?
1. My husband will do well as long as I keep him engaged in activities he likes.
2. My focus is learning how to live my life.
3. I'm so glad our problems are behind us.
4. I'll make sure that the children don't give my husband any problems.
2. My focus is learning how to live my life. Correct- working to change codependent behavior
1. My husband will do well as long as I keep him engaged in activities he likes. - Wife accepts responsibility- codependency
3. I'm so glad our problems are behind us. Unrealistic
4. I'll make sure that the children don't give my husband any problems. - Wife accepts responsibility Codependent behavior
116
Which medication is used for an alcoholic who hasn't had a drink in 5 hours.
1. Chlordiazepoxide
2. Disulfiram
3. Methadone
4. Naloxone
1. Chlordiazepoxide - Antianxiety
2. Disulfiram: (Antiabuse) deters compulsive drinking. Contraindicated with in 12 hrs of alcohol consumption
117
Postexposure to hep A,B, & C profilaxis
HBIG (A&B)
None for C
118
Emphysema patient becomes restless & confused. What action should the nurse take next?
1. Encourage Pursed lip breathing
2. Measure clients temp
3. Assess clients K level
4. Increase oxygen to 5L/ min
1. Encourage Pursed lip breathing
Helps control rate & depth of breathing
2. Measure clients temp
3. Assess clients K level
4. Increase oxygen to 5L/ min (CAUTION: COPD emphysema should receive low flow oxygen)
119
After intracranial surgery
Medications (4)
HOB
Daily Fluid
Osmotic diuretics, corticosteroids, anticonvulsant, & stool softeners (prevents valsalva maneuver)
HOB 30- 45 degrees - promotes Venus return from brain & prevents ICP.
Fluid restriction 1,200 - 1,500
120
Hyperemesis gravidarum is a complication of early pregnancy and has these S&S
Severe N&V & Weight loss
121
Emergency cesarean birth
Which will be Delegated to the LPN
1. Notify blood bank
2. Insert indwelling catheter
3. Explain procedure to the clients family
4. Providing report to the neonatal ICU
2. Insert indwelling catheter
(RN)
1. Notify blood bank
4. Providing report to the neonatal ICU
(HCP)
3. Explain procedure to the clients family
122
Pernicious anemia is caused by ....
Symptoms
Failure to absorb vitamin B¹² due to lack of intrinsic factors in gut mucosa
Symptoms: Pallor, jaundice, glossitis, fatigue, weight loss, paresthesia of hands & feet, balance & gait.
123
Chronic bronchitis, audible wheezes, Ox Sat of 85% - 88% 4 hours ago.
Most important action
1. Give 2 puffs Beclomethasone
2. Ausculate bilateral breath sounds
3. Increase oxygen rate to 4L/Minute via mask
4. Administer 2 puffs Albuterol
4. Administer 2 puffs Albuterol
(Bronchodilator- opens up airways and allows other medicine to work.)
1.Give 2 puffs Beclomethasone
(Admin Bronchodilator first -rol)
2. Ausculate bilateral breath sounds
No further assessment needed
3. Increase oxygen rate to 4L/Minute via mask (COPD - emphysema & chronic bronchitis cannot tolerate too much oxygen)
124
Proper posistion for a PET brain scan
PET uses radioactive isotopes that are uptake by tissues, damaged tissue more than regular.
What special precaution is needed with urine
Flat on back with a small pillow
No urine precautions.
Consume lots of fluid to rid body of isotopes
125
Asthma client prescribed neostigmine IM. Best action for nurse to take.
1. Administer medicine
2. Obtain BP & Pulse
3. Ask pharmacist if med can be given orally
4. NOTIFY HCP
4. NOTIFY HCP
Cholinergic causes bronchoconstruction.
1. Administer medicine
2. Obtain BP & Pulse
3. Ask pharmacist if med can be given orally
126
Describe appearance of Addisons disease who has received steroid therapy for several years.
Truncal obesity
Purple striations on skin
Moon face
Buffalo hump
127
Which statement by Anorexic is most concerning
1. My gums bled this morning
2. I'm getting fatter everyday
3. Nobody likes me, I'm ugly
4. I feel dizzy and weak today
4. I feel dizzy and weak today
Masolow needs. Physiological over Psychosocial
128
Why can't a person with Pneumocystis jiroveci & Kaposi Sarcoma be organ donors
Pneumocystis jiroveci (fungal lung infection- immune compromised) & Kaposi Sarcoma (Aids lesions) be organ donors
Aids patients can't be organ donors
129
After laparoscopic cholecystectomy client reports pain & bloating. Which is best response
1. Increase intake of fresh fruit & vegetables
2. I'll give you prescribed pain medication
3. We can try talking down the hallway together
4. You may need an indwelling catherer
3. We can try talking down the hallway together (Carbon Dioxide insufflated during surgery causes pain. Ambulation increases absorption of CO²)
1.Increase intake of fresh fruit & vegetables - No indication of Constipation
2. I'll give you prescribed pain medication
4. You may need an indwelling catherer
130
Which will an LPN assist
1. Client with MRI of brain in the morning
2. Unconscious client who needs bed bath
3. Client in balanced suspension traction
4. Client with diabetes who needs help bathing
3. Client in balanced suspension traction - stable
131
Client underwent vagotomy with antrectomy for treatment if a duodenal ulcer - developed Dumping syndrome
Which statement indicates more Teaching is needed
1. I should eat bread with each meal
2. I should eat smaller meals more often
3. I should lie down after eating
4. I should avoid drinking fluids with my meals
1. I should eat bread with each meal
(Carbs should not be limited with dumping syndrome- protein enchanced)
Rest are true
Laying down after delays stomach emptying time
132
Antrectomy...
Treats stomach bleeding & block Removes lower 1/3rd of stomach
Also reduces acid secreting portion of stomach
133
Client with a new colostomy
Teaching was successful when they select
1. Sausage, sauerkraut, baked potatoes, fresh fruit
2. Cheese omelet with bran muffin and fresh pineapple
3. Pork chops, mashed potatoes, turnips, salad.
4. Baked chicken, boiled potatoes, cooked carrots and yogurt
4. Baked chicken, boiled potatoes, cooked carrots and yogurt
Goal diet 4 - 6 postop colostomy
Low-residue, no gas-forming, odor-producing, laxative or Constipating foods
1. Sausage, sauerkraut, baked potatoes, fresh fruit (Sausage & Sauekraut gas producing)
2. Cheese omelet with bran muffin and fresh pineapple (High Fiber - Residue)
3. Pork chops, mashed potatoes, turnips, salad. (Turnips odor causing, salad residue)
134
Breast feeding is recommended for how long
How many wet diapers daily
How long do new borns sleep between feedings
How long do breast feed babies feed
6 - 12 months
6 - 8 diapers daily
2-3hrs day & 4 at night
15 - 20 minutos per breast
135
Breast feeding is recommended for how long
6 - 12 months
136
During V fib a client gets defibed.
The purpose of defibrillation is to
Deliver an electric current to the heart that (depolarizes / Repolarizes) myocardial cells. When the cells (depolarize / Repolarize) the ___ node commonly recaptures its role as the pacemaker of the heart
Depolarize / Repolarize
SA node (pacemaker of heart)
AV node (gatekeeper of heart - slows down beats)
137
What type of pain is most characteristic of MI
Chestpain radiating to neck, jaw, shoulder, back, left arm - unrelieved by Nitroglycerin
Fever
Apprehension
Dizzy
Diaphoresis
Palpitations
SOB
138
First choice for LPN to reduce risk of Pooled airway secretions and decreased chest wall expansion
1. Chest Percussion
2. Incentive Spirometry
3. Posistion Change
4. Postural Drainage
3. Posistion Change
139
Risk factors
History of varicose veins, hypercoagulation, cardiovascular disease, pregnancy, oral contraceptives, Immobility, recent surgery or injury
DVT
Clot formation in a vein secondary to inflammation of vein or partial vein obstruction
140
Risk factors:
History of varicose veins, hypercoagulation, cardiovascular disease, pregnancy, oral contraceptives, Immobility, recent surgery, injury
DVT
Clot formation in a vein secondary to inflammation of vein of partial vein obstruction
141
Which of the following laws allows a mentally stable patient to leave AMA (against medical advice) from a hospital
Common law
Precedent law
Civil law
State law
Common law
142
It is imperative that a nurse advocates for a patient. Which of the following describes a nurse advocating for a patient
A. Giving an opinion on different medical treatments for patient to select best option
B. Telling patient who is the best surgeon to perform his / her surgery
C. Explain test results in depth after a physician gives initial results
D. Telling the patient that it is best not to take all their meds as to not become more ill
C. Explain test results in depth after a physician gives initial results
A nurse can explain test results after a Dr. Has given the results
143
What is the name of a collaborative approach that supports suggested treatment plans to ensure that patients with disabilities, illnesses, or injuries receive proper medical care?
A. Delegation
B. Case Management
C. Care plan
D. Clinical approach
B. Case Management
144
What is the Acronym for what a nurse should do during a fire
RACE
Rescue
Alarm
Contain
Extinguish
145
Patients with sensory changes are at the highest risk for which of the following
A. Isolation
B. Depression
C. Anxiety
D. Decreased Physical Endurance
Isolation
146
If a patient is smoking what do you do immediately
A. Notify nurse manager
B. Tell patient to put out the cigarette
C. Pull fire alarm
D. Turn off oxygen
Tell them to put it out
147
If stuck by a needle what is the first step
A. Wash hands soap and water 15 minutes
B. Go to employee health immediately
C. Report incident
D. Obtain needle and place in sharps container
Wash hands 15 minutes
Encourage it to bleed when washing
148
Mom doesn't want vaccines for children. What is the most appropriate response
A. I understand. Here are pamphlets incase you change your mind
B. As you wish
C. I understand. If you would like some pamphlets I can give you some
D. I understand. But this will put your children at high risk for preventable disease
C. I understand. If you would like some pamphlets I can give you some
149
New born weighs 8 lb 5 oz
3 days later which of the following weights would cause concern
A. 8 lb 2 oz
B. 7 lb 7 oz
C. 7 lb 6 oz
D. 8lb 13 oz
7lb 6 oz
It is normal for a new born to lose 10% of birth weight but after 1 week it should return to birth weight
7lb 6 oz is more than 10%
150
Who eats more often breastfeeding or formula-feeding babies?
Or is it the same
Breastfeed more
Milk digest quicker
151
Which would you expect in discharge for a patient with ETOH abuse
A. Education on drinking in moderation
B. Prescription for Naltrexone
C. Therapy to help drink in moderation
D. Education on self-control
Naltrexone
Naltrexone blocks the euphoric and sedative effects of drugs such as heroin, morphine, and codeine.
152
What is cyclothymia
Psyc disorder
Ups & Down but not as severe as Bi-Polar
153
Which should be included in the plan of care at home for a patient with new diagnosed Alzheimer's
Frequent orientation
Behavior therapy
Cognitive Remediation
Social Interventions
Frequent Orientation
154
When administrating a IM injection at 90° which method do you use to ensure that fluid doesn't leak into the SQ tissue
Z track
pulling the tissue beside the injection site to cause a displacement of the skin and fatty tissue over the muscular tissue which will be injected into the muscle
155
Which is not a concern when administration of an enema to an older adult
A. Hypercalcemia
B. Hyperphosphatemia
C. Sepsis
D. Bowel perforation
A. Hypercalcemia
They are at risk for Hypocalcemia
156
Patient recieves Humalog at 8am
When do they need to start eating their breakfast
A. Before 9AM
B. 815 AM
C. 845 AM
D. Before 930 AM
Before 815
157
Dr. Orders enoxaparin sodium for a patient who is chairfast. What angle do you anticipate injecting this medication if their BMI is 23
45
90
180
30
23 is a normal BMI
A sub q injection will be 45 ° angle
158
Patient is prescribed Warfarin for a recent blood clots
Which food should not be consumed
Lettuce
Eggs
Milk
Olives
Lettuce
Contains vitamin K which reduces effects of Warfarin
159
Which position would you put a patient with a sudden gastrointestinal bleed
Trendelenburg
Supine
Reverse Trendelenburg
Sims
Trendelenburg
This will increase BP.
Their BP will be low due to blood loss
160
Diabetic patient is sweating and onl able to mumble
What is the first invention
Give Glucagon
Check POC glucose reading
Ask patient when they last ate
4 units of insulin
Check POC First
161
Patient is having a seizure which is the most important intervention
Admin oxygen
Place patient in side laying position
Insert IV
Call immediate assistance from health care team
Call immediate help
162
Nurse is about to assist a physician in a Lumbar puncture for a patient with suspected bacterial meningitis.
Which position should the patient be in?
Lateral decubitus
