NCLEX PREP QUESTIONS.
The nurse receives report on 4 clients. Which client should the nurse see first?
1. Client admitted 12 hours ago with acute asthma exacerbation who needs a
dose of IV methylprednisolone [21%]
2. Client admitted 2 days ago with congestive heart failure who is reporting shortness of
breath and had an extra dose of furosemide prescribed recently [55%]
3. Client admitted with intestinal obstruction who is reporting abdominal pain and
distention and needs nasogastric tube placement [17%]
4. Client who had cardiac valve surgery 8 days ago but was readmitted with a sternal wound
infection and needs antibiotics and a dressing change [6%]
Although it is not a STAT order, an extra dose of furosemide was prescribed for the client with
congestive heart failure. The shortness of breath is most likely due to a change in fluid status,
and this client is the priority. Furosemide works immediately and should be given urgently.
(Option 1) Even though this client has asthma exacerbation, steroids (methylprednisolone
[Solu-Medrol]) do not show their effect immediately. These drugs control underlying
inflammation but take several hours/days to take effect. Bronchodilators such as albuterol
or ipratropium work immediately.
Educational objective:
A client who is experiencing symptoms that could compromise airway, breathing, or
circulation should be seen first.
What works immediately ASTHMA
work immediately ASTHMABronchodilators such as albuterol or ipratropium
A 59-year-old client comes to the clinic due to a blistering, linear rash on the left chest. The
client reports itching and pain around the rash. What is the priority question for the nurse
to ask the client?
1. "Did the rash start after taking a new medication?"
2. "Have you been keeping the rash
covered?" 3. "
4. "What have you tried to help the
pain?" Correct Answered correctly
Have you ever had chickenpox?"
{NI}
f this rash is determined to be due to shingles, the affected area should be covered to
prevent the spread of infection. Therefore, it is a priority to ask if this client has had
chickenpox.
AIRBORN ISOLATION N-95
can occur in clients with a history of chickenpox (varicella-zoster virus exposure). The
vesicular rash has a characteristic, linear dermatomal distribution and can present with
severe pain. Vaccination prevents shingles.
Herpes zoster (shingles) CDC& Prevention recommends shingle vaccine for use in people
60 years old and older to prevent shingles
Why should nurse anticipate the health care provider transferring to the intensive care unit?
82-year-old with pressure (decubitus) ulcer who has a change in mental status,
temperature of 96.4 F (35.8 C), pulse of 110/min, and blood pressure of 96/72 mm Hg
[69%]
Sepsis
is a potentially life-threatening condition.
Physiologic changes related to the aging process, including decreased immune function and
,NCLEX PREP QUESTIONS.
inflammatory response (immunosenescence) and altered febrile response to pyrogens,
increase the risk for sepsis.
can be the presenting feature of sepsis in elderly clients.
,NCLEX PREP QUESTIONS.
Hypothermia
abnormally high levels of nitrogen-containing
compounds azotemia
60-year-old with chronic kidney disease who has a blood pressure of 168/88 mm Hg,
serum creatinine level of 5.0 mg/dL (442 µmol/L), and reports nausea and itching [15%]
EXPECTED Hypertension, elevated serum creatinine level (normal: 0.6-1.3 mg/dL [53-115
µmol/L]), nausea associated with azotemia, and pruritus associated with dry skin are
expected for chronic kidney disease clients.
early recognition of sepsis is critical to survival, atypical presentation associated with
immunosenescence and absence of fever can delay diagnosis and treatment.
early sepsis
Systemic inflammatory response
syndrome Finding Value
Temperature >100.4 °F or
<96.8 °F Heart rate >90/min
Respiratory rate >20/min or PaCO2<32 mmHg
(4.3 kPa) WBC <4000/mm³, >12x109/L
(>12,000/mm³), or 10% ban The influenza virus
has an incubation period
of 1-4 days, with peak transmission starting at about 1 day before symptoms appear and
lasting up to 5-7 days after the illness stage begins
Influenza is transmitted by
inhaling droplets that an infected individual exhales into the air when sneezing,
coughing, or speaking vaccination provides immunity against influenza in about
2 weeks after inoculation, it does not offer complete protection against all virus strains.
Therefore, close contact with others should be avoided during the illness stage, especially
those with an impaired immune system.
Influenza is a highly contagious respiratory infection transmitted by
airborne droplets and direct contact. It has an incubation period of 1-4 days, with peak
transmission starting at about 1 day before symptoms appear and lasting up to 5-7 days
after the illness stage begins. Vaccination does not offer complete protection against all
virus strains.
Femoral-popliteal bypass surgery
involves circumventing a blockage in the femoral artery with a synthetic or autogenous
(artery or vein) graft to restore blood flow.
Femoral-popliteal bypass surgery[NI]
The nurse performs neurovascular assessments on the affected extremity (ie, pulses, color
and skin temperature, capillary refill, pain, movement) and compares the findings with the
preoperative baselinen. on palpable pedal pulse that is present only with Doppler distal to
the graft (ie, post-tibial, pedal) can indicate compromised blood flow or graft occlusion and
should be reported to the health care provider immediately!!!!!
the inability of the leg veins to efficiently pump blood back to the heart. It can lead to
venous stasis, increased hydrostatic pressure, and venous leg ulcers. Edema and thick skin
with brown pigmentation are expected manifestations
Chronic venous insufficiency
Gangrene of the foot is a complication of associated with decreased
blood flow to the extremity.
peripheral arterial disease
(PAD) expected
manifestations of PAD
Coolness of the skin and shiny, hairless legs, feet, and toes
Intermittent claudication is leg pain caused by decreased blood flow to the muscles that
reoccurs during activity such as walking and dissipates with rest. expected
Intermittent claudication
Absent or decreased volume in the peripheral pulses distal to the graft can
indicate compromised circulation or graft occlusion and should be reported to the health
care provider immediately!!!!! ABC!
, NCLEX PREP QUESTIONS.
percutaneous endoscopic gastrostomy (PEG) tube
The nurse receives report on 4 clients. Which client should the nurse see first?
1. Client admitted 12 hours ago with acute asthma exacerbation who needs a
dose of IV methylprednisolone [21%]
2. Client admitted 2 days ago with congestive heart failure who is reporting shortness of
breath and had an extra dose of furosemide prescribed recently [55%]
3. Client admitted with intestinal obstruction who is reporting abdominal pain and
distention and needs nasogastric tube placement [17%]
4. Client who had cardiac valve surgery 8 days ago but was readmitted with a sternal wound
infection and needs antibiotics and a dressing change [6%]
Although it is not a STAT order, an extra dose of furosemide was prescribed for the client with
congestive heart failure. The shortness of breath is most likely due to a change in fluid status,
and this client is the priority. Furosemide works immediately and should be given urgently.
(Option 1) Even though this client has asthma exacerbation, steroids (methylprednisolone
[Solu-Medrol]) do not show their effect immediately. These drugs control underlying
inflammation but take several hours/days to take effect. Bronchodilators such as albuterol
or ipratropium work immediately.
Educational objective:
A client who is experiencing symptoms that could compromise airway, breathing, or
circulation should be seen first.
What works immediately ASTHMA
work immediately ASTHMABronchodilators such as albuterol or ipratropium
A 59-year-old client comes to the clinic due to a blistering, linear rash on the left chest. The
client reports itching and pain around the rash. What is the priority question for the nurse
to ask the client?
1. "Did the rash start after taking a new medication?"
2. "Have you been keeping the rash
covered?" 3. "
4. "What have you tried to help the
pain?" Correct Answered correctly
Have you ever had chickenpox?"
{NI}
f this rash is determined to be due to shingles, the affected area should be covered to
prevent the spread of infection. Therefore, it is a priority to ask if this client has had
chickenpox.
AIRBORN ISOLATION N-95
can occur in clients with a history of chickenpox (varicella-zoster virus exposure). The
vesicular rash has a characteristic, linear dermatomal distribution and can present with
severe pain. Vaccination prevents shingles.
Herpes zoster (shingles) CDC& Prevention recommends shingle vaccine for use in people
60 years old and older to prevent shingles
Why should nurse anticipate the health care provider transferring to the intensive care unit?
82-year-old with pressure (decubitus) ulcer who has a change in mental status,
temperature of 96.4 F (35.8 C), pulse of 110/min, and blood pressure of 96/72 mm Hg
[69%]
Sepsis
is a potentially life-threatening condition.
Physiologic changes related to the aging process, including decreased immune function and
,NCLEX PREP QUESTIONS.
inflammatory response (immunosenescence) and altered febrile response to pyrogens,
increase the risk for sepsis.
can be the presenting feature of sepsis in elderly clients.
,NCLEX PREP QUESTIONS.
Hypothermia
abnormally high levels of nitrogen-containing
compounds azotemia
60-year-old with chronic kidney disease who has a blood pressure of 168/88 mm Hg,
serum creatinine level of 5.0 mg/dL (442 µmol/L), and reports nausea and itching [15%]
EXPECTED Hypertension, elevated serum creatinine level (normal: 0.6-1.3 mg/dL [53-115
µmol/L]), nausea associated with azotemia, and pruritus associated with dry skin are
expected for chronic kidney disease clients.
early recognition of sepsis is critical to survival, atypical presentation associated with
immunosenescence and absence of fever can delay diagnosis and treatment.
early sepsis
Systemic inflammatory response
syndrome Finding Value
Temperature >100.4 °F or
<96.8 °F Heart rate >90/min
Respiratory rate >20/min or PaCO2<32 mmHg
(4.3 kPa) WBC <4000/mm³, >12x109/L
(>12,000/mm³), or 10% ban The influenza virus
has an incubation period
of 1-4 days, with peak transmission starting at about 1 day before symptoms appear and
lasting up to 5-7 days after the illness stage begins
Influenza is transmitted by
inhaling droplets that an infected individual exhales into the air when sneezing,
coughing, or speaking vaccination provides immunity against influenza in about
2 weeks after inoculation, it does not offer complete protection against all virus strains.
Therefore, close contact with others should be avoided during the illness stage, especially
those with an impaired immune system.
Influenza is a highly contagious respiratory infection transmitted by
airborne droplets and direct contact. It has an incubation period of 1-4 days, with peak
transmission starting at about 1 day before symptoms appear and lasting up to 5-7 days
after the illness stage begins. Vaccination does not offer complete protection against all
virus strains.
Femoral-popliteal bypass surgery
involves circumventing a blockage in the femoral artery with a synthetic or autogenous
(artery or vein) graft to restore blood flow.
Femoral-popliteal bypass surgery[NI]
The nurse performs neurovascular assessments on the affected extremity (ie, pulses, color
and skin temperature, capillary refill, pain, movement) and compares the findings with the
preoperative baselinen. on palpable pedal pulse that is present only with Doppler distal to
the graft (ie, post-tibial, pedal) can indicate compromised blood flow or graft occlusion and
should be reported to the health care provider immediately!!!!!
the inability of the leg veins to efficiently pump blood back to the heart. It can lead to
venous stasis, increased hydrostatic pressure, and venous leg ulcers. Edema and thick skin
with brown pigmentation are expected manifestations
Chronic venous insufficiency
Gangrene of the foot is a complication of associated with decreased
blood flow to the extremity.
peripheral arterial disease
(PAD) expected
manifestations of PAD
Coolness of the skin and shiny, hairless legs, feet, and toes
Intermittent claudication is leg pain caused by decreased blood flow to the muscles that
reoccurs during activity such as walking and dissipates with rest. expected
Intermittent claudication
Absent or decreased volume in the peripheral pulses distal to the graft can
indicate compromised circulation or graft occlusion and should be reported to the health
care provider immediately!!!!! ABC!
, NCLEX PREP QUESTIONS.
percutaneous endoscopic gastrostomy (PEG) tube
