NCLEX RN k
STUDY GUIDE
k
GRADED A
k
, NCSBN ON-LINE REVIEW 2021-2022
k k k
1.Akclientkhaskbeenkhospitalizedkafterkankautomobilekaccident.kAkfullklegkcastkwaskappliedkinkthekemergencykroom.kThek most
importantkreasonkforktheknursektokelevatekthekcastedklegkiskto
Promotekthekclient'skcomfort
kReducekthekdryingk timekDecr
easekirritationktokthekskinkImp
rovekvenouskreturn
D:kImprovekvenouskreturn.kElevatingktheklegkbothkimproveskvenouskreturnkandkreduceskswelling.kClientkcomfortkwillkbekim
provedkaskwell.
Theknursekiskreviewingkwithkakclientkhowktokcollectkakcleankcatchkurinekspecimen.kWhatkiskthekappropriateksequencektokte
achkthekclient?
Cleankthekmeatus,kbeginkvoiding,kthenkcatchkurinekstrea
mkVoidkaklittle,kcleankthekmeatus,kthenkcollectkspecimenk
Cleankthekmeatus,kthenkurinatekintokcontainer
Voidkcontinuouslykandkcatchksomekofkthekurine
A:kCleankthekmeatus,kbeginkvoiding,kthenkcatchkurinekstream.kAkcleankcatchkurinekiskdifficultktokobtainkandkrequireskclearkdi
rections.kInstructingkthekclientktokcarefullykcleankthekmeatus,kthenkvoidknaturallykwithkaksteadykstreamkpreventsksurfacekba
cteriakfromkcontaminatingkthekurinekspecimen.kAskstartingkandkstoppingkflowkcankbekdifficult,koncekthekclientkbeginskvoidi
ngkit’skbestktokjustkslipkthekcontainerkintokthekstream.kOtherkresponseskdoknotkreflectkcorrectktechnique
Followingkchange-of-shiftkreportkonkankorthopedickunit,kwhichkclientkshouldktheknursekseekfirst?
16kyear-
oldkwhokhadkankopenkreductionkofkakfracturedkwristk10khourskagok20kye
ar-
oldkinkskeletalktractionkfork2kweeksksincekakmotorkcyclekaccidentk72kyea
r-
oldkrecoveringkfromksurgerykafterkakhipkreplacementk2khourskagok75kyea
r-oldkwhokiskinkskinktractionkpriorktokplannedkhipkpinningksurgery.
C:kLookkforkthekclientkwhokhaskthekmostkimminentkriskskandkacutekvulnerability.kThekclientkwhokreturnedkfromksurgeryk2kh
ourskagokiskatkriskkforklifekthreateningkhemorrhagekandkshouldkbekseenkfirst.kThek16kyear-
koldkshouldkbekseenknextkbecausekitkiskstillkthekfirstkpost-opkday.kThek75kyear-koldkiskpotentiallykvulnerablektokage-
relatedkphysicalkandkcognitivekconsequenceskinkskinktractionkshouldkbekseenknext.kThekclientkwhokcanksafelykbekseenklastkis
kthek20kyear-oldkwhokisk2kweekskpost-injury.
AkclientkwithkGuillainkBarrekiskinkaknonresponsivekstate,kyetkvitalksignskarekstablekandkbreathingkiskindependent.kWhatksho
uldktheknursekdocumentktokmostkaccuratelykdescribekthekclient'skcondition?
Comatose,kbreathingkunlabored
GlascowkComakScalek8,krespirationskregularkApp
earsktokbeksleeping,kvitalksignskstablekGlascowkC
omakScalek13,knokventilatorkrequired
B:kGlascowkComakScalek8,krespirationskregular.kThekGlascowkComakScalekprovideskakstandardkreferencekforkassessingkorkm
onitoringklevelkofkconsciousness.kAnykscoreklesskthank13kindicateskakneurologicalkimpairment.kUsingkthektermkcomatosekpr
ovidesktookmuchkroomkforkinterpretationkandkisknotkverykprecise.
Whenkcaringkforkakclientkreceivingkwarfarinksodiumk(Coumadin),kwhichklabktestkwouldktheknursekmonitorktokdeterminekthe
rapeutickresponsektokthekdrug?
BleedingktimekCoa
gulationktimekProt
hrombinktime
Partialkthromboplastinktime
C:kProthrombinktime.kCoumadinkiskorderedkdaily,kbasedkonkthekclient''skprothrombinktimek(PT).kThisktestkevaluateskthekade
quacykofkthekextrinsicksystemkandkcommonkpathwaykinkthekclottingkcascade;kCoumadinkaffectskthekVitaminkKkdependentkc
lottingkfactors.
clientkwithkmoderatekpersistentkasthmakiskadmittedkforkakminorksurgicalkprocedure.kOnkadmissionkthekpeakkflowkmeterkiskm
easuredkatk480kliters/minute.kPost-
operativelykthekclientkiskcomplainingkofkchestktightness.kThekpeakkflowkhaskdroppedktok200kliters/minute.kWhatkshouldkthe
knursekdokfirst?
Notifykbothktheksurgeonkandkprovide
,rkAdministerkthekprnkdosekofkalbutero
l
Applykoxygenkatk2klitD
eroswpnelorandaesdalbcya:knkinsuhlea |
RepeatkthekpeakkflowkreaDdisintrgibiunti3o0nko mfkitnhuistedsocumentkiskillegal
, Stuvia.comk-kThekMarketplacektokBuykandkSellkyourkStudykMaterial
A) Thekclientklostk2kpoundskink24khours
Thekclient’skpotassiumklevelkisk4kmEq/liter.
Thekclient’skurinekoutputkwask1500kcckink5khours
ThekclientkisktokreceivekanotherkdosekofkLasixkatk10kPM
C:kThekclient’skurinekoutputkwask1500kcckink5khours.kAlthoughkallkofkthesekmaykbekcorrectkinformationktokincludekinkrep
ort,kthekessentialkpiecekwouldkbekthekurinekoutput.
8.AkclientkhaskbeenktentativelykdiagnosedkwithkGraves'kdiseasek(hyperthyroidism).kWhichkofkthesekfindingsknotedkonkthekinitial
nursingkassessmentkrequireskquickkinterventionkbyktheknurse?
akreportkofk10kpoundskweightklosskinktheklastkmont
hkakcommentkbykthekclientk"Ikjustkcan'tksitkstill."
thekappearancekofkeyeballskthatkappearktok"pop"koutkofkthekclient'skeyeksocke
tskakreportkofktheksuddenkonsetkofkirritabilitykinkthekpastk2kweeks
C:kthekappearancek ofkeyeballskthatkappeark tok"pop"koutkofkthekclient''skeyek sockets.kExophthalmoskorkprotrudingk eyeballs
kiskakdistinctivekcharacteristickofkGraves''kDisease.kItkcankresultkinkcornealkabrasionskwithkseverekeyekpainkorkdamagekwhenk
thekeyelidkiskunablektokblinkkdownkoverkthekprotrudingkeyeball.kEyekdropskorkointmentkmaykbekneeded.
Theknursekhaskperformedkthekinitialkassessmentskofk4kclientskadmittedkwithkankacutekepisodekofkasthma.kWhi
chkassessmentkfindingkwouldkcausektheknursektokcallkthekproviderkimmediately?
prolongedkinspirationkwithkeachkbreath
expiratorykwheezeskthatkareksuddenlykabsentkink1klobekexpect
orationkofklargekamountskofkpurulentkmucouskappearancekofkt
hekusekofkabdominalkmuscleskforkbreathing
B:kexpiratorykwheezeskthatkareksuddenlykabsentkink1klobe.kAcutekasthmakiskcharacterizedkbykexpiratorykwheezeskcausedkb
ykobstructionkofkthekairways.kWheezeskarekakhighkpitchedkmusicalksoundskproducedkbykairkmovingkthroughknarrowedkairw
ays.kClientskoftenkassociatekwheezeskwithkthekfeelingkofktightnesskinkthekchest.kHowever,ksuddenkcessationkofkwheezingkis
kankominouskorkbadksignkthatkindicateskankemergencyk --ktheksmallkairwayskareknowkcollapsed.
10. Duringkthekinitialkhomekvisit,kaknursekiskdiscussingkthekcarekofkakclientknewlykdiagnosedkwithkAlzheimer'skdiseasekwithkfa
milykmembers.kWhichkofkthesekinterventionskwouldkbekmostkhelpfulkatkthisktime?
leavekakbookkaboutkrelaxationktechniques
writekoutkakdailykexercisekroutinekforkthemktokassistkthekclientktok
doklistkactionsktokimprovekthekclient'skdailyknutritionalkintake
suggestkcommunicationkstrategies
D:ksuggestkcommunicationkstrategies.kAlzheimer''skdisease,kakprogressivekchronickillness,kgreatlykchallengeskcaregivers.kTh
eknursekcankbekofkgreatestkassistancekinkhelpingkthekfamilyktokusekcommunicationkstrategiesktokenhancektheirkabilityktokrel
atektokthekclient.kBykusekofkselectkverbalkandknonverbalkcommunicationkstrategieskthekfamilykcankbestksupportkthekclient’sk
strengthskandkcopekwithkanykaberrantkbehavior.
11. Ank80kyear-
oldkclientkadmittedkwithkakdiagnosiskofkpossiblekcerebralkvascularkaccidentkhaskhadkakbloodkpressurekfromk160/100ktok180/1
10koverkthekpastk2khours.kTheknursekhaskalsoknotedkincreasedklethargy.kWhichkassessmentkfindingkshouldktheknursekreportk
immediatelyktokthekprovider?
SlurredkspeechkIn
continencekMuscl
ekweaknesskRapid
kpulse
A:kSlurredkspeech.kChangeskinkspeechkpatternskandklevelkofkconsciouskcankbekindicatorskofkcontinuedkintracranialkbleedingk
orkextensionkofkthekstroke.kFurtherkdiagnosticktestingkmaykbekindicated.
Akschool-
agedkchildkhaskhadkaklongklegk(hipktokankle)ksynthetickcastkappliedk4khourskago.kWhichkstatementkfromkthekparentkindica
teskthatkteachingkhaskbeenkinadequate?
"Ikwillkkeepkthekcastkuncoveredkforktheknextkdayktokpreventkburningkofkthekskin
."k"Ikcankapplykankicekpackkoverkthekareaktokrelievekitchingkinsidekthekcast."
"Thekcastkshouldkbekproppedkonkatkleastk2kpillowskwhenkmykchildkisklyingkdown
."k"IkthinkkIkrememberkthatkmykchildkshouldknotkstandkuntilkafterk72khours."
STUDY GUIDE
k
GRADED A
k
, NCSBN ON-LINE REVIEW 2021-2022
k k k
1.Akclientkhaskbeenkhospitalizedkafterkankautomobilekaccident.kAkfullklegkcastkwaskappliedkinkthekemergencykroom.kThek most
importantkreasonkforktheknursektokelevatekthekcastedklegkiskto
Promotekthekclient'skcomfort
kReducekthekdryingk timekDecr
easekirritationktokthekskinkImp
rovekvenouskreturn
D:kImprovekvenouskreturn.kElevatingktheklegkbothkimproveskvenouskreturnkandkreduceskswelling.kClientkcomfortkwillkbekim
provedkaskwell.
Theknursekiskreviewingkwithkakclientkhowktokcollectkakcleankcatchkurinekspecimen.kWhatkiskthekappropriateksequencektokte
achkthekclient?
Cleankthekmeatus,kbeginkvoiding,kthenkcatchkurinekstrea
mkVoidkaklittle,kcleankthekmeatus,kthenkcollectkspecimenk
Cleankthekmeatus,kthenkurinatekintokcontainer
Voidkcontinuouslykandkcatchksomekofkthekurine
A:kCleankthekmeatus,kbeginkvoiding,kthenkcatchkurinekstream.kAkcleankcatchkurinekiskdifficultktokobtainkandkrequireskclearkdi
rections.kInstructingkthekclientktokcarefullykcleankthekmeatus,kthenkvoidknaturallykwithkaksteadykstreamkpreventsksurfacekba
cteriakfromkcontaminatingkthekurinekspecimen.kAskstartingkandkstoppingkflowkcankbekdifficult,koncekthekclientkbeginskvoidi
ngkit’skbestktokjustkslipkthekcontainerkintokthekstream.kOtherkresponseskdoknotkreflectkcorrectktechnique
Followingkchange-of-shiftkreportkonkankorthopedickunit,kwhichkclientkshouldktheknursekseekfirst?
16kyear-
oldkwhokhadkankopenkreductionkofkakfracturedkwristk10khourskagok20kye
ar-
oldkinkskeletalktractionkfork2kweeksksincekakmotorkcyclekaccidentk72kyea
r-
oldkrecoveringkfromksurgerykafterkakhipkreplacementk2khourskagok75kyea
r-oldkwhokiskinkskinktractionkpriorktokplannedkhipkpinningksurgery.
C:kLookkforkthekclientkwhokhaskthekmostkimminentkriskskandkacutekvulnerability.kThekclientkwhokreturnedkfromksurgeryk2kh
ourskagokiskatkriskkforklifekthreateningkhemorrhagekandkshouldkbekseenkfirst.kThek16kyear-
koldkshouldkbekseenknextkbecausekitkiskstillkthekfirstkpost-opkday.kThek75kyear-koldkiskpotentiallykvulnerablektokage-
relatedkphysicalkandkcognitivekconsequenceskinkskinktractionkshouldkbekseenknext.kThekclientkwhokcanksafelykbekseenklastkis
kthek20kyear-oldkwhokisk2kweekskpost-injury.
AkclientkwithkGuillainkBarrekiskinkaknonresponsivekstate,kyetkvitalksignskarekstablekandkbreathingkiskindependent.kWhatksho
uldktheknursekdocumentktokmostkaccuratelykdescribekthekclient'skcondition?
Comatose,kbreathingkunlabored
GlascowkComakScalek8,krespirationskregularkApp
earsktokbeksleeping,kvitalksignskstablekGlascowkC
omakScalek13,knokventilatorkrequired
B:kGlascowkComakScalek8,krespirationskregular.kThekGlascowkComakScalekprovideskakstandardkreferencekforkassessingkorkm
onitoringklevelkofkconsciousness.kAnykscoreklesskthank13kindicateskakneurologicalkimpairment.kUsingkthektermkcomatosekpr
ovidesktookmuchkroomkforkinterpretationkandkisknotkverykprecise.
Whenkcaringkforkakclientkreceivingkwarfarinksodiumk(Coumadin),kwhichklabktestkwouldktheknursekmonitorktokdeterminekthe
rapeutickresponsektokthekdrug?
BleedingktimekCoa
gulationktimekProt
hrombinktime
Partialkthromboplastinktime
C:kProthrombinktime.kCoumadinkiskorderedkdaily,kbasedkonkthekclient''skprothrombinktimek(PT).kThisktestkevaluateskthekade
quacykofkthekextrinsicksystemkandkcommonkpathwaykinkthekclottingkcascade;kCoumadinkaffectskthekVitaminkKkdependentkc
lottingkfactors.
clientkwithkmoderatekpersistentkasthmakiskadmittedkforkakminorksurgicalkprocedure.kOnkadmissionkthekpeakkflowkmeterkiskm
easuredkatk480kliters/minute.kPost-
operativelykthekclientkiskcomplainingkofkchestktightness.kThekpeakkflowkhaskdroppedktok200kliters/minute.kWhatkshouldkthe
knursekdokfirst?
Notifykbothktheksurgeonkandkprovide
,rkAdministerkthekprnkdosekofkalbutero
l
Applykoxygenkatk2klitD
eroswpnelorandaesdalbcya:knkinsuhlea |
RepeatkthekpeakkflowkreaDdisintrgibiunti3o0nko mfkitnhuistedsocumentkiskillegal
, Stuvia.comk-kThekMarketplacektokBuykandkSellkyourkStudykMaterial
A) Thekclientklostk2kpoundskink24khours
Thekclient’skpotassiumklevelkisk4kmEq/liter.
Thekclient’skurinekoutputkwask1500kcckink5khours
ThekclientkisktokreceivekanotherkdosekofkLasixkatk10kPM
C:kThekclient’skurinekoutputkwask1500kcckink5khours.kAlthoughkallkofkthesekmaykbekcorrectkinformationktokincludekinkrep
ort,kthekessentialkpiecekwouldkbekthekurinekoutput.
8.AkclientkhaskbeenktentativelykdiagnosedkwithkGraves'kdiseasek(hyperthyroidism).kWhichkofkthesekfindingsknotedkonkthekinitial
nursingkassessmentkrequireskquickkinterventionkbyktheknurse?
akreportkofk10kpoundskweightklosskinktheklastkmont
hkakcommentkbykthekclientk"Ikjustkcan'tksitkstill."
thekappearancekofkeyeballskthatkappearktok"pop"koutkofkthekclient'skeyeksocke
tskakreportkofktheksuddenkonsetkofkirritabilitykinkthekpastk2kweeks
C:kthekappearancek ofkeyeballskthatkappeark tok"pop"koutkofkthekclient''skeyek sockets.kExophthalmoskorkprotrudingk eyeballs
kiskakdistinctivekcharacteristickofkGraves''kDisease.kItkcankresultkinkcornealkabrasionskwithkseverekeyekpainkorkdamagekwhenk
thekeyelidkiskunablektokblinkkdownkoverkthekprotrudingkeyeball.kEyekdropskorkointmentkmaykbekneeded.
Theknursekhaskperformedkthekinitialkassessmentskofk4kclientskadmittedkwithkankacutekepisodekofkasthma.kWhi
chkassessmentkfindingkwouldkcausektheknursektokcallkthekproviderkimmediately?
prolongedkinspirationkwithkeachkbreath
expiratorykwheezeskthatkareksuddenlykabsentkink1klobekexpect
orationkofklargekamountskofkpurulentkmucouskappearancekofkt
hekusekofkabdominalkmuscleskforkbreathing
B:kexpiratorykwheezeskthatkareksuddenlykabsentkink1klobe.kAcutekasthmakiskcharacterizedkbykexpiratorykwheezeskcausedkb
ykobstructionkofkthekairways.kWheezeskarekakhighkpitchedkmusicalksoundskproducedkbykairkmovingkthroughknarrowedkairw
ays.kClientskoftenkassociatekwheezeskwithkthekfeelingkofktightnesskinkthekchest.kHowever,ksuddenkcessationkofkwheezingkis
kankominouskorkbadksignkthatkindicateskankemergencyk --ktheksmallkairwayskareknowkcollapsed.
10. Duringkthekinitialkhomekvisit,kaknursekiskdiscussingkthekcarekofkakclientknewlykdiagnosedkwithkAlzheimer'skdiseasekwithkfa
milykmembers.kWhichkofkthesekinterventionskwouldkbekmostkhelpfulkatkthisktime?
leavekakbookkaboutkrelaxationktechniques
writekoutkakdailykexercisekroutinekforkthemktokassistkthekclientktok
doklistkactionsktokimprovekthekclient'skdailyknutritionalkintake
suggestkcommunicationkstrategies
D:ksuggestkcommunicationkstrategies.kAlzheimer''skdisease,kakprogressivekchronickillness,kgreatlykchallengeskcaregivers.kTh
eknursekcankbekofkgreatestkassistancekinkhelpingkthekfamilyktokusekcommunicationkstrategiesktokenhancektheirkabilityktokrel
atektokthekclient.kBykusekofkselectkverbalkandknonverbalkcommunicationkstrategieskthekfamilykcankbestksupportkthekclient’sk
strengthskandkcopekwithkanykaberrantkbehavior.
11. Ank80kyear-
oldkclientkadmittedkwithkakdiagnosiskofkpossiblekcerebralkvascularkaccidentkhaskhadkakbloodkpressurekfromk160/100ktok180/1
10koverkthekpastk2khours.kTheknursekhaskalsoknotedkincreasedklethargy.kWhichkassessmentkfindingkshouldktheknursekreportk
immediatelyktokthekprovider?
SlurredkspeechkIn
continencekMuscl
ekweaknesskRapid
kpulse
A:kSlurredkspeech.kChangeskinkspeechkpatternskandklevelkofkconsciouskcankbekindicatorskofkcontinuedkintracranialkbleedingk
orkextensionkofkthekstroke.kFurtherkdiagnosticktestingkmaykbekindicated.
Akschool-
agedkchildkhaskhadkaklongklegk(hipktokankle)ksynthetickcastkappliedk4khourskago.kWhichkstatementkfromkthekparentkindica
teskthatkteachingkhaskbeenkinadequate?
"Ikwillkkeepkthekcastkuncoveredkforktheknextkdayktokpreventkburningkofkthekskin
."k"Ikcankapplykankicekpackkoverkthekareaktokrelievekitchingkinsidekthekcast."
"Thekcastkshouldkbekproppedkonkatkleastk2kpillowskwhenkmykchildkisklyingkdown
."k"IkthinkkIkrememberkthatkmykchildkshouldknotkstandkuntilkafterk72khours."
