NCLEX-RN Live Review health care 2021/22

Increased myocardial oxygen use a. Bronchodilators cause tachycardia b. Decreases the amount of oxygen available for the rest of the body c. HYPOkalemia and HYPERglycemia are caused by bronchodilator therapy 2. Recurring calf pain after walking one to two blocks that disappears with rest. Weak pedal pulses, skin on left leg (lower leg) is shiny and cool to touch. Which nursing interventions? a. Intermittent claudication (arterial insufficiency) b. Position the leg dependently (put it down-blood will flow down) c. Venous insufficiency (leg would go UP) d. Arterial (letters go down in the capital A) e. Venous insufficiency (put the legs UP like the letters in V) Blood is only good for 4 hours (starting from when you leave the lab) 3. New tracheostomy, at home, the nurse recognizes a need for IMMEDIATE intervention when the caregiver does which of the following? LIVE REVIEW a. Life threatening! b. Removes old tracheostomy ties before the new ones are secured (decannulate themself) Maslow’s Hierarchy of Needs Self actualization (not a lot of questions) Self esteem (not a lot of questions) Love and belonging Safety and security Physiological - COMES first, unless there is an immediate risk for suicide ABC’s (not always airway first) Nursing process (not always assess first) Safety and risk reduction 4. Client sustained a c3 spinal cord injury. What finding should the nurse recognize as priority of care? ● C4 and above affects the muscles for breathing ● C1/C2 on a ventilator immed. ● Respirations 10/min would be the priority 5. Nurse prepares an older adult for a scheduled colonoscopy. Which should be the nurse’s INITIAL action? ● Place portable commode at bedside ● After physiological (prior to surgery so there are no physiological issues yet), next is safety. 6. Client ER reports HX Gravida 3 Para 2. Initial Action after observing a presenting part? ● Prepare for delivery of the newborn in the ER. ● Client is already effaced and fully dilated. ● If you can DELEGATE something to a non licensed person, it's not your priority. 7. Nurse enters the room of a client who is at the foot of the bed lying on the floow. Nurses initial action? ● Assess vital signs and LOC (before the person ended up on the floor, they had to be conscious) FIRST. Mass Casualties (Pg. 22) Up and down traffic light is the order you save them. Least Restrictive/invasive Acute OVER Chronic (Acute always take priority with one exception, the chronic condition has exacerbated to the point that it is life threatening ex. Status asthmaticus) Stable vs. Unstable Red immediate Yellow delayed LIVE REVIEW Green minor Black (Require the most man power, equipment, supplies, etc.) 8. Four days after ventral hernia repair, a client who is obese and has a hx of COPD vomits and reports severe abdominal pain. The oxygen sat is 90%. Which action should the nurse implement first? ● Assess the surgical incision site. ● Client is OBESE so that puts them at risk for dehiscence and evisceration. ● 90% for a COPD client is acceptable. 9. Client who is 24 hours post acute MI and reports “I can't breathe now that I am lying down after lunch” Nurse’s initial action ● Place client in high-fowler’s position ● Least invasive action 10. Nurse arrives at a work site explosion. Which client should be triaged first? ● Burns to the face and respiratory stridor (occlusion in airway) ● Fixed pupils and agonal respirations (random gasps of air) would get a black tag 11. Nurse is coordinating client care. Which client should the nurse delegate to the PN? A client who ● Requires insertion of an indwelling urinary catheter ● NOTHING new/initial. ● Only reinforcement 12. An adolescent client was admitted 12 hours ago following mvc. Multiple skeletal fractures were sustained. Client is in balanced suspension traction. Which assessment finding requires immediate intervention by the nurse. ● Disorientation (change is mentation/LOC)***** potentially life threatening. ● Bloody drainage at the pin site is an expected finding 13. Nurse provides care for a client who is scheduled for ECT. Which medication should the nurse withhold prior to therapy? ● Phenytoin (seizure medication) - You would not give this cause ECT causes seizures ● Atropine sulate (anticholinergic effects) ● Methohexital (short acting for sedation) ● Succinylcholine (paralytics) 14. A home health nurse is performing an admission assessment on a client who had a knee arthroplasty one week ago. Which client statement should concern the nurse the most? ● I am so glad to be off those blood thinners ● Risk for DVT ● Should be on anticoagulants: 3-6 months ● Pillow should be under calf and heel ● No wheelchair. Needs crutches or walker ● Ibuprofen is an NSAID and increases risk for bleeding on top of the blood thinners the patient is already consuming 15. Client has not voided 8 hours following the removal of an indwelling bladder catheter. What should be the nurse’s initial action? LIVE REVIEW ● Perform bladder scan 16. Nurse provides care for a client who has a chest tube. The nurse notes the chest tube has become disconnected from the chest drainage system. Which action should the nurse take? ● Immerse the end of the chest tube in a bottle of a sterile water ● Recreating a temporary water seal 17. Older adult dies from the complications of a CVA, the client’s partner is present at the bedside. Which action should the nurse take? ● Stay with the partner at the bedside 18. Client dx with rheu arthritis, receive 3 months of methotrexate therapy. Which of the following are adverse effects associated with the therapy? SATA ● WBC: 1,200 (neutropenic) ● Platelets: 5,000 (very low) ● Causes stomatitis (weight loss) ● Urine specific gravity: 1.003 (low) HIGH AND DRY not low for methotrexate ● Fever (greater than 101) 19. A nurse is organizing care for a group of clients. Which task should the nurse assign the AP? ● Assist a client who is requesting a bedpan 1 day post of hysterectomy ● AP’s take routine vitals, do not take any vitals that are considered assessment vitals. 20. A nurse is observing a client attempt three point crutch walking (pg. 71). Which action should be of concern to the nurse? ● The client moves leg with opposite arm 21. A school nurse observes several children playing on a playground. Which child should concern the nurse most? ● Defect is ventricular septal (hole in the septum between the the ventricles)*surpassing the lungs* blood that is oxygenated is going out to the patient's body. Kidneys may not out as much urine. ● Right ventricular hypertrophy (big and large, won’t pump like it's supposed to. s/s of right sided heart failure- jvd, dependant edema, ascites ● Overriding aorta (lays down between the right and left ventricle. Decreased cardiac output cause its not sending blood out to the body) ● Pulmonic stenosis (between the right ventricle and the lungs, narrowed, some backflow of blood) ● Tetralogy of Fallot - Squat 22. A client who is semi comatose after CVA, has a NG tube, and was started on TPN. Which action should the nurse implement to prevent fluid volume deficit? ● Monitor blood glucose every 4-6 hr. ● Hyperglycemia - polyuria ● Osmotic diuresis ● Sliding scale insulin Authoritative Very little autonomy LIVE REVIEW CODES very helpful Lassez-Faire Very good in ICU Democratic Everyone has input, everyone is included Communication (pg. 10-11) Conflict Resolution ● Intrapersonal conflict- occurs within yourself ● Interpersonal- between two people ● Intergroup- between units, day shift versus night shift Best solution for conflict is always a win-win Collaborating - win/win Cooperating - lose/win Competing - win/lose Smoothing - lose/lose Avoiding - lose/lose 23. SATA: A nurse prepares a staff in service on incident reports. Which info should the nurse include? 1. Risk mgt investigates the incident 2. Reports include description of incident and actions taken 3. Reports are confidential and not shared with non involved staff **Do not write in nurse’s notes incident report completed** 24. Nurse is unsure of the proper technique when caring for a client who is prescribed enteral feedings. Which action should the nurse take? ● Consult the unit procedure manual for guidance. 25. A nurse admits a client from a long term care facility. Which action should be implemented? SATA 1. Verify the admission meds prescribed the the provider 2. Review the current med regimen with client 3. Obtain the most recent list of meds from the long term care facility 4. Discuss any discrepancies with the health care provider PN’s do not assess. PN can increase oxygen flow but a AP cannot AP can gather/document - I/O’s AP can ambulate a client who had a laparoscopic appendectomy four hours ago Care plans are RN responsibility Novice RN… prove competency PN cannot give Rhogam - CANNOT GIVE BLOOD PRODUCTS LIVE REVIEW Can give epigen PNs no ivs PN can administer 2nd dose (first bag of anything has to be done by an RN!) NO IV pushes by PN (ex. ondansetron) Any client who has a med that needs to be titrated is not considered stable so only RN can do it. 26. A nurse cares for a client with terminal lung cancer. whIch action should be delegated to the AP? ● Assist the client to ambulate to the bedside chair twice a day ● Complete vitals q 4 hr ● CANNOT touch the indwelling bladder catheter (sterile) 27. Cares for a group of clients on a med surg unit. Which client should be delegated to the pn. SATA ● Bronchitis receiving bronchodilator treatments ● Advanced reg diet two days post op cholecystectomy 28. Nurse assigns 4 clients to the pn. Which Finding should the PN immed. Report to the nurse? ● Baseline regular apical pulse of 88 who has an irregular pulse of 120 today.