(STUDY GUIDE & 500+ TERMS)
600+ PRACTICE QUESTIONS
Expert-Verified Explanations & Solutions
Qs & Ans to Pass the Exam
The Study guide consists of
Nclex-Rn Exam 500+ Terms
600+ PRACTICE Questions
multiple-choice items
multiple response,
fill-in-the-blank calculation,
ordered response, and hot spot questions.
Expert-Verified Explanations & Solutions
,The nurse is caring for a client who reports feeling faint and is
experiencing the cardiac rhythm shown in the electrocardiogram (ECG)
strip below.
- BRADYCARDIA (it is more than 5 spaces apart, sinus rhythm)
Which of the following actions would be appropriate for the nurse to take?
Select all that apply:
1. Administer the client's prescribed beta blocker.
2. Prepare for transcutaneous pacing.
3. Instruct the client to perform the Valsalva maneuver.
4. Begin chest compressions.
5. Assess the client for angina.
2. transcutaneous pacing
- external pacing that stimulates the ventricles to pump at a set rate
5. Assess the client for angina
- Angina (Chest pain) can be caused by both tachycardia (most common) and
bradycardia (rare but can happen). Assessment of angina is appropriate
Rationale:
1. Beta blocker would further decrease HR
3. Valsalva maneuver/Vagal stimulation would further decrease HR. (can be
indicated for sinus Tachy)
4. Chest compressions are for cardiac arrest
The nurse is planning care for a client with moderate Alzheimer's disease
(AD).
Which of the following interventions should the nurse include in the
client's plan of care?
1. Encourage the client to reminisce about happy memories.
2. Confront the client when inappropriate or agitated behaviors occur.
3. Administer to the client the cholinesterase inhibitor to reverse the
course of AD.
4. Provide the client with information about activity choices in the
morning so the client can make plans for the day.
,1. Encourage the client to reminisce about happy memories.
Its possible for AD patients to retain long-term memories
Rationale:
2. Acknowledge feelings --> Redirect is protocol for Dementia. Don't confront;
they can't learn
3. AD is irreversible
4. In moderate AD, dementia has already progressed to where pt needs help
with ADLs and planning daily activities. Asking them to plan can frustrate
them and cause distress.
STRUCTURED pleasant activities that consider the persons likes and interests
are the best.
The nurse is teaching a client how to ambulate using crutches. Which of
the following information should the nurse include?
1. "Use your hands and arms to support your body weight."
2. "Wear slippers when ambulating with the crutches in your home."
3. "Maintain the crutches 12 in (30 cm) in front of your feet while standing."
4. "Adjust the hand grips of the crutches so that your elbows are fully
extended."
1. "Use your hands and arms to support your body weight."
True! But watch out if it isn't 2-3 finger-widths, crutch paralysis can occur. s/s:
paresis and paresthesias in wrists and hands
Rationales:
2. Fall risk!
3. Should be 6 in. in front and 6 in. lateral
4. Elbows should be bent at 30 degree angle
The nurse has taught a client with multiple sclerosis (MS).
Which of the following statements by the client would indicate a correct
understanding of the teaching?
1. "I will complete all of my household chores in the morning when I am
, well rested."
2. "I have learned how to massage my bladder to help empty my bladder
completely."
3. "I will take a hot bath in the evening to help me relax if I have had a
stressful day at work."
4. "I should expect the blurred vision to resolve after I have received
medications for several weeks."
4. "I should expect the blurred vision to resolve after I have received
medications for several weeks."
MS causes nerve damage and can result in optic neuritis (vision loss, burry
vision). In most cases it resolves itself in 4-12 weeks, but medication (steroids)
can speed up the process and resolve it quicker
Rationale:
1. MS patients should not exert themselves too much at one time. Space out
activities and allow time for rest.
2. Urinary retention is primarily treated by medication (bethanochol), and
exercises can aid with it but are not the primary treatment
3. Hot temperatures are bad for MS and can worsen symptoms. Your nerves
are already fcked up and extra heat can stress your body into overdrive
The nurse has attended a sta: education program about caring for clients
who are receiving positive pressure mechanical ventilation. Which of the
following statements by the nurse would indicate a correct understanding
of the teaching?
1. "Clients should avoid range-of-motion (ROM) exercises until weaned
from ventilation."
2. "Clients may develop stress ulcers and gastrointestinal bleeding."
3. "Clients will be chemically paralyzed to improve oxygenation."
4. "Clients will experience diuresis and polyuria."