Exam (elaborations)
NCLEX REVIEW STUDY GUIDE (SUMMER 2022)
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NCLEX REVIEW STUDY GUIDE (SUMMER 2022)
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NCLEX REVIEW STUDY GUIDE (SUMMER 2022)1. A child with 20% second and third degree burns is admitted to the
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cburn center. The child weighs 44lbs (20 kg). The nurse has started an IV
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cinfusion of lactated ringer solution and inserted an indwelling catheter.
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cWhich of the findings indicate that the child is going into shock?
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(Select all that apply) c c c
a. Urinary output is 25ml/hr c c c
b. Client is confused c c
c. Pain is 7 on a pain scale 1-10
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d. Heart rate is elevated c c c
e. Blood pressure is dropping: Client is
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confused Heart rate is elevated
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Blood pressure is dropping
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2. A 17 year old high school senior calls the clinic because she thinks
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she might have gonorrhea. She wants to be seen but wants assurances
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that no one will know. Which is the most appropriate response by the
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nurse?
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a. "Because you are underage, you will need your parent's consent to
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treat you"
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b. "We can treat you without your parent's consent, but they have the right
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to review your medical record"
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c. "We can see you without your parents consent, but have to report
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any positive results to the public health department"
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d. "We can see you, treat any infection, and will not share your results
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with anyone": "We can see you without your parents consent, but
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have to report any positive results to the public health department"
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3. The parents of a child with sickle cell anemia ask about the chances
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of sickle cell disease occurring in future children. The nurse responds
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based on knowledge that both parents are carriers. What is the risk of
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one of their children having the disease?
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,a. one chance in five for each pregnancy
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b. one chance in four for each pregnancy
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c. one chance in three for each pregnancy
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d. one chance in two for each pregnancy: one chance in four for each
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pregnancy
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4. The nurse assesses a client's risk for breast cancer. Which finding would
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be considered a risk factor?
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a. Menopause before age 40
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,b. Early onset of menstruation
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c. Having more than 2 children c c c c
d. Breastfeeding longer than 2 years.: Early onset of menstruation c c c c c c c c
5. The nurse determines that a client's abdominal wound has
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eviscerated. What should the nurse do first?
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a. Notify the healthcare provider
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b. Reinsert the protruding viscera into the abdominal cavity.
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c. Place the client in reverse Trendelenburg's position
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d. Cover the wound with sterile saline-moistened dressing: Cover the
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wound with sterile saline-moistened dressing
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6. An older adult is admitted to the hospital with sudden onset of severe
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pain in the back, flank, and abdomen. The client reports feeling weak; the
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blood pressure is 68/31 mm hg. There has been no urine output. Bilateral
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cleg pulses are weak, although bruit and pulsation are noted at the
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cumbilicus. What action should the nurse take first?
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a. Obtain consent for emergency surgery
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b. Assess leg pulses with a Doppler test
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c. Palpate the abdomen for presence of a mass
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d. Start an IV infusion.: Start an IV infusion
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7. A preterm infant born 2 hours ago at 34 weeks' gestation is
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experiencing rapid respirations, grunting, no breathe sounds on one
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side, and shift in location of heart sounds. The nurse should prepare to
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assist with which procedure?
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a. Placement of the neonate on a ventilator c c c c c c
b. Administration of bronchodilators through the nares c c c c c
c. Suctioning of the neonate's nares with wall suction c c c c c c c
d. Insertion of a chest tube into the neonate: Insertion of a chest tube
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into the neonate
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8. The nurse is evaluating a client who is using a flow incentive
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spirometer following abdominal surgery 1 day ago. The client is performing
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the procedure correctly when the client does what?
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Select all that apply
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a. inhales before using the spirometer
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b. inhales for 3 second following fully expanding the lungs
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c. coughs after suing the spirometerc c c c
, d. uses the spirometer once every 8 hours
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e. exhales passively before using the spirometer again c c c c c c
f. sits upright: inhales for 3 second following fully expanding
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cthe lungs coughs after suing the spirometer
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exhales passively before using the c c c c
cspirometer again sits upright c c c
9. A client receiving chemotherapy for metastatic colon cancer is
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cadmitted to the hospital because of prolonged vomiting. Assessment
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cfindings include irregular pulse of 120 bpm, blood pressure 88/48 mm Hg,
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crespiratory rate of 14 breathes/min, serum potassium of 2.9 mEq/L (2.9
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cmmol/L) and arterial blood gas -pH 7.46, PCO2 45 mm Hg (6.0 kPA), P)2 95
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cmm HG (12.6 kPa), bicarbonate level 29 mEq/L (29 mmol/L) The nurse
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cshould implement which prescription first?
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a. oxygen at 4L per nasal cannula c c c c c
b. repeat laboratory work in 4 hours c c c c c
c. D5W 45% NS with KCl 40 mEq/L at 125 mL/h
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d. 12 lead ECG: D5W 45% NS with KCl 40 mEq/L at 125 mL/h
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10. The nurse observes a constant gentle bubbling in the water-seal
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column of a water-seal chest drainage system. What action should the
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nurse take?
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a. continue monitoring as usual; this is expected c c c c c c
b. check the connectors between the chest and drainage tubes and where
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the drainage tube enters the chest drainage system.
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c. decrease the suction, and continue observing the system for changes
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in bubbling during the next several hours.
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d. Notify the healthcare provider.: check the connectors between the
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chest and drainage tubes and where the drainage tube enters the
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chest drainage system.
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11. A client experienced a pneumothorax after the placement of central
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venous pressure line. Which assessment supports a diagnosis of
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pneumothorax?
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a. sudden, sharp pain on the affected side c c c c c c
b. tracheal deviation toward the affected side c c c c c
c. bradypnea and elevated blood pressure c c c c
d. presence of crackles and wheezes.: sudden, sharp pain on the affected
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side c
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