3/16/2023 Kaplan NCLEX Readiness Exam Flashcards | Quizlet
Kaplan NCLEX Readiness Exam
Terms in this set (180)
The nurse cares for a client 1) CORRECT - Implementation: outcome desired;
with a cuffed tracheostomy cuff inflation decreases the risk of aspiration; cuff
tube. Before performing oral position and pressure should be assessed
care, the nurse notes that the frequently; swallowing and breathing will cause
client's tracheostomy cuff is tracheostomy tube movement
inflated. Which of the following
is the MOST appropriate action 2) Implementation: outcome not desired;
for the nurse to take? accumulated oral secretions above the cuff will
drain into the bronchi; increased risk of infection
1. Leave the cuff inflated and
suction through the 3) Implementation: outcome not desired; cuff
tracheostomy. pressure should be less than 20 mm Hg (25 cm
2. Deflate the cuff and suction H2O); risk of trauma to trachea with higher
through the tracheostomy pressures
tube.
3. Inflate the cuff pressure to 4) Implementation: outcome not desired; increases
40 mm Hg before suctioning. the risk of trauma to lower airways
4. Adjust the wall suction
pressure to 160 to 180 mm Hg
before suctioning.
1/139
,3/16/2023 Kaplan NCLEX Readiness Exam Flashcards | Quizlet
A young adult brings a friend 1) Assessment: outcome not priority but may be
to the emergency department appropriate; pinpoint pupils are a sign of heroin
and states that the friend has overdose
been using heroin. Which
action by the nurse is the 2) CORRECT - Assessment: outcome priority;
MOST appropriate? shallow respirations seen; impaired alveolar gas
exchange and possible respiratory arrest
1. Assess pupil size and
reactivity. 3) Assessment: outcome not priority; most
2. Assess oxygen saturation important to assess airway and breathing
levels.
3. Palpate dorsalis pedis 4) Assessment: outcome not priority but may be
pulses. appropriate; drowsiness and euphoria may be seen;
4. Ask the client if he knows not priority
today's date.
The client tells the clinic nurse 1) Assessment: outcome not priority but may be
that the client is thinking about appropriate; can be asked as part of assessment
using nicotine polacrilex
(Nicorette). Which question is 2) Assessment: outcome not priority but may be
MOST important for the nurse appropriate; should be assessed for further
to ask? teaching
1. "Have you tried other 3) CORRECT - Assessment: outcome priority; action
methods to stop smoking?" of nicotine is vasoconstriction; increases heart rate
2. "How long have you been and myocardial oxygen consumption; increased risk
smoking?" of angina and myocardial infarction
3. "Have you ever had chest
pain?" 4) Assessment: outcome may be appropriate but
4. "Do you have a partial dental not priority; gum is place between cheek and gums;
bridge?" may stain dental work
2/139
,3/16/2023 Kaplan NCLEX Readiness Exam Flashcards | Quizlet
The nurse cares for the client 1) Assessment: outcome not priority but may be
with a client controlled appropriate; if tubing is obstructed, alarm is
analgesia (PCA) pump. The activated
nurse determines that the client
has pressed the button 11 times 2) Assessment: outcome may be appropriate but
and received 6 doses of not priority; more important to determine pain level,
morphine during the last hour. description of the pain, region and radiation of the
Which is the MOST appropriate pain, and relieving factors
action for the nurse to take?
3) Implementation: outcome not desired; more
1. Assess the patency of the important to assess severity of pain and pain relief
PCA IV tubing. first
2. Determine the client's
understanding of the PCA 4) CORRECT - Assessment: outcome priority; must
pump function. validate that client is in pain before implementation
3. Obtain an order to begin a
PCA infusion of fentanyl.
4. Ask the client to describe the
pain.
3/139
, 3/16/2023 Kaplan NCLEX Readiness Exam Flashcards | Quizlet
A pregnant woman receives an 1) Implementation: outcome not desired; no
epidural anesthetic. After increase in venous return
administration of the epidural
anesthetic, the client's blood 2) Implementation: outcome not desired; will
pressure changes from 120/84 decrease venous return
to 94/50. Which action by the
nurse is MOST appropriate? 3) CORRECT - Implementation: outcome desired;
will increase venous return and cardiac output; fetal
1. Place the client flat on her pressure on inferior vena cava reduced
back.
2. Elevate the head of the bed 4) Implementation: outcome not desired; elevation
30 degrees. of legs will increase venous return, but fetal
3. Place the client on her left pressure on vena cava will prevent blood return to
side with her legs flexed. heart
4. Place the client supine with
the foot of the bed elevated.
A nursing order, "Increase fluid 1) CORRECT - Assessment: outcome priority;
intake" is written for a client increased amounts of antidiuretic hormone
diagnosed with dehydration. secreted; urine output decreased and concentrated
Which finding BEST indicates
improving fluid status? 2) Assessment: outcome not priority; indicates that
blood is hemoconcentrated
1. Urinary output of 1,500 mL in
24 hours. 3) Assessment: outcome not priority; normal intake
2. Serum hematocrit 52%. is 1,500 mL in 24 hours
3. Oral fluid intake of 900 mL in
24 hours. 4) Assessment: outcome not priority; normal BP is
4. Blood pressure of 100/82. 120/80
4/139
Kaplan NCLEX Readiness Exam
Terms in this set (180)
The nurse cares for a client 1) CORRECT - Implementation: outcome desired;
with a cuffed tracheostomy cuff inflation decreases the risk of aspiration; cuff
tube. Before performing oral position and pressure should be assessed
care, the nurse notes that the frequently; swallowing and breathing will cause
client's tracheostomy cuff is tracheostomy tube movement
inflated. Which of the following
is the MOST appropriate action 2) Implementation: outcome not desired;
for the nurse to take? accumulated oral secretions above the cuff will
drain into the bronchi; increased risk of infection
1. Leave the cuff inflated and
suction through the 3) Implementation: outcome not desired; cuff
tracheostomy. pressure should be less than 20 mm Hg (25 cm
2. Deflate the cuff and suction H2O); risk of trauma to trachea with higher
through the tracheostomy pressures
tube.
3. Inflate the cuff pressure to 4) Implementation: outcome not desired; increases
40 mm Hg before suctioning. the risk of trauma to lower airways
4. Adjust the wall suction
pressure to 160 to 180 mm Hg
before suctioning.
1/139
,3/16/2023 Kaplan NCLEX Readiness Exam Flashcards | Quizlet
A young adult brings a friend 1) Assessment: outcome not priority but may be
to the emergency department appropriate; pinpoint pupils are a sign of heroin
and states that the friend has overdose
been using heroin. Which
action by the nurse is the 2) CORRECT - Assessment: outcome priority;
MOST appropriate? shallow respirations seen; impaired alveolar gas
exchange and possible respiratory arrest
1. Assess pupil size and
reactivity. 3) Assessment: outcome not priority; most
2. Assess oxygen saturation important to assess airway and breathing
levels.
3. Palpate dorsalis pedis 4) Assessment: outcome not priority but may be
pulses. appropriate; drowsiness and euphoria may be seen;
4. Ask the client if he knows not priority
today's date.
The client tells the clinic nurse 1) Assessment: outcome not priority but may be
that the client is thinking about appropriate; can be asked as part of assessment
using nicotine polacrilex
(Nicorette). Which question is 2) Assessment: outcome not priority but may be
MOST important for the nurse appropriate; should be assessed for further
to ask? teaching
1. "Have you tried other 3) CORRECT - Assessment: outcome priority; action
methods to stop smoking?" of nicotine is vasoconstriction; increases heart rate
2. "How long have you been and myocardial oxygen consumption; increased risk
smoking?" of angina and myocardial infarction
3. "Have you ever had chest
pain?" 4) Assessment: outcome may be appropriate but
4. "Do you have a partial dental not priority; gum is place between cheek and gums;
bridge?" may stain dental work
2/139
,3/16/2023 Kaplan NCLEX Readiness Exam Flashcards | Quizlet
The nurse cares for the client 1) Assessment: outcome not priority but may be
with a client controlled appropriate; if tubing is obstructed, alarm is
analgesia (PCA) pump. The activated
nurse determines that the client
has pressed the button 11 times 2) Assessment: outcome may be appropriate but
and received 6 doses of not priority; more important to determine pain level,
morphine during the last hour. description of the pain, region and radiation of the
Which is the MOST appropriate pain, and relieving factors
action for the nurse to take?
3) Implementation: outcome not desired; more
1. Assess the patency of the important to assess severity of pain and pain relief
PCA IV tubing. first
2. Determine the client's
understanding of the PCA 4) CORRECT - Assessment: outcome priority; must
pump function. validate that client is in pain before implementation
3. Obtain an order to begin a
PCA infusion of fentanyl.
4. Ask the client to describe the
pain.
3/139
, 3/16/2023 Kaplan NCLEX Readiness Exam Flashcards | Quizlet
A pregnant woman receives an 1) Implementation: outcome not desired; no
epidural anesthetic. After increase in venous return
administration of the epidural
anesthetic, the client's blood 2) Implementation: outcome not desired; will
pressure changes from 120/84 decrease venous return
to 94/50. Which action by the
nurse is MOST appropriate? 3) CORRECT - Implementation: outcome desired;
will increase venous return and cardiac output; fetal
1. Place the client flat on her pressure on inferior vena cava reduced
back.
2. Elevate the head of the bed 4) Implementation: outcome not desired; elevation
30 degrees. of legs will increase venous return, but fetal
3. Place the client on her left pressure on vena cava will prevent blood return to
side with her legs flexed. heart
4. Place the client supine with
the foot of the bed elevated.
A nursing order, "Increase fluid 1) CORRECT - Assessment: outcome priority;
intake" is written for a client increased amounts of antidiuretic hormone
diagnosed with dehydration. secreted; urine output decreased and concentrated
Which finding BEST indicates
improving fluid status? 2) Assessment: outcome not priority; indicates that
blood is hemoconcentrated
1. Urinary output of 1,500 mL in
24 hours. 3) Assessment: outcome not priority; normal intake
2. Serum hematocrit 52%. is 1,500 mL in 24 hours
3. Oral fluid intake of 900 mL in
24 hours. 4) Assessment: outcome not priority; normal BP is
4. Blood pressure of 100/82. 120/80
4/139
