a nurse of the telemetry unit is worrying for a co
a nurse growing a plan of care for a patron with a
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NCLEX NGN Pre-Test Questions
A nurse is assigned to take care of a consumer with persistent renal failure who is
undergoing hemodialysis via an inner AV fistula in the RA. Which intervention should the
nurse implement in being concerned for the customer? SATA
a. Assessing the radial pulse within the right extremity
b. Using the LA ti take BP readings
c. Drawing pre-dialysis blood specimens from the LA
d. Assessing the area over the AV fistula for a bruit and three every shift
e. Placing a stress dressing over the web site after every dialysis remedy
f. Administering IV fluids through the venous web site of the AV fistula as wanted - ANSA, B,
C, D
A nurse is comparing effects for a purchaser with Guillain-Barre syndrome. Which outcome
does the nurse apprehend as superior respiratory results for the purchaser?
A. Normal deep tendon reflexes
b. Improved skeletal muscle tone
c. Absences of paresthesias inside the decrease extremities
d. Clear sound within the decrease lung fields bilaterally
e. PO2 of 85 mmHg and pCO2 of 40 mmHg - ANSD, E
A nurse of the telemetry unit is worrying for a consumer who has had a MI and is now
attached to a cardiac display. The nurse is monitoring the consumer's cardiac rhythm and
nots ventricular fibrillation. Which nursing intervention ought to the nurse take first?
A. Calling the rapid reaction crew
b. Preparing the consumer for cardioversion
c. Asking the client to endure down and cough
d. Preparing to manage diltiazem - ANSA
The sample of ventricular fibrillation is identified and can be a result after a affected person
with an MI. VF makes the affected person feel faint, then loses attention and will become
pulseless and apneic (BP and heart sounds absent). Treatment is to terminate VF and covert
it right into a rhythm via defibrillation-> name a rapid and initiate CPR. Cardioversion is used
for ventricular or supraventricular tachydysrhythmias.
A nurse growing a plan of care for a patron with a spinal wire damage consists of measures
to save you autonomic dysreflexia (hyperreflexia). Which intervention does the nurse include
into the plan to save you this complication?
A. Keeping the fan jogging in the purchaser's room
b. Keeping the linens wrinkle unfastened underneath the client
c. Limiting bladder catheterization to as soon as every 12 hours
d. Avoiding the administration of enemas and rectal suppositories - ANSB
The most frequent cause of autonomic dysreflexias are a distended bladder and impacted
feces. Other reasons encompass stimulation of the pores and skin through tactile, thermal,
or painful stimuli. The nurse renders care in one of these way as to minimize these dangers.
,A nurse presents domestic care instructions to a consumer who has been equipped with a
halo tool to treat a cervical fracture. Which assertion through the purchaser shows the want
for in addition coaching?
A. I need to get more fluids and fiber into my diet
b. I ought to reduce my meals into small portions before I devour
c. I need to position powder underneath the vest twice an afternoon to prevent sweating
d. I actually have to check the pin web sites regular and watch for symptoms of
contamination - ANSC
Cleanse the skin under the wool liner each day to save you rashes and soars.
A nurse is caring for a patron with extended intracranial pressure. In which position should
the nurse preserve the client?
A. Supine with the top extended
b. Side mendacity with the neck flexed
c. Supine with the pinnacle turned to the aspect
d. Head midline and accelerated 30-forty five tiers - ANSD
Proper positioning promotes venous drainage from the skull to decrease ICP.
A customer with a basilar cranium fracture has clean fluid leaking from the ears. The nurse
ought to take which motion first?
A. Asses the clear fluid for protein
b. Check the clean fluid for glucose
c. Place cotton calls or dry gauze loosely inside the ears
d. Use an otoscope to evaluate the tympanic membrane for rupture - ANSB
CSF consists of glucose no longer protein.
A nurse is being concerned for a patron who has just undergone cardioversion. Which
intervention is the nurse's precedence after this method.
A. Administer oxygen
b. Monitoring the BP
c. Administering antidysrhythmic medicines
d. Monitoring the client's LOC - ANSA
ABC's of nursing. All other selections are accurate, however now not precedence.
A client with diabetes mellitus who is scheduled to have blood drawn for dedication of the
glycosylated hemoglobin (HbA1c) level asks the nurse why the check is vital if he is
performing blood glucose monitoring at domestic. Which is the first-class reaction for the
nurse to provide?
A. Detect diabetic headaches
b. Assess lengthy-term glycemic control
c. Determine whether the consumer is at risk for hypoglycemia
d Determine whether or not the prescribed insulin dosage is correct - ANSB
A nurse worrying for a patron with received immunodeficiency syndrome is tracking the client
for signs and symptoms of complications. Which of the following would motive the nurse to
suspect contamination with Pneumocystis jirovec? SATA
a. Diarrhea
b. Tachypnea
, c. Pedal edema
d. Intermittent fever
e. Dyspnea with ambulating
f. Expectoration of frothy mucus - ANSB, D, E
A opportunistic breathing infection related to AIDs that causes dyspnea, nonproductive
cough, intermittent fever, fatigue, anorexia, tachypnea, wt. Loss.
Zidovudine is prescribed for a purchaser with AIDS. The nurse tells the purchaser that it's far
vital to document returned to the medical institution as scheduled for which comply with-up
diagnostic?
A. Blood glucose exams
b. Blood pressure exams
c. Complete blood counts (CBC)
d. Electrocradiographic research - ANSC
Zidovudine is an antiviral medication that reason motive agranulocytosis and anemia.
After a non-immunocompromised consumer undergoes a Mantoux check for TB
contamination, a place of induration 6 mm huge developed. The customer asks the nurse
what this end result approach. Which is the first-class reaction?
A. We'll must repeat the take a look at due to the fact the result changed into inconclusive
b. The swollen location is small, so which means your take a look at end result is negative
c. You've been exposed to TB so that you will need to have a chest x-ray
d. You want to get started on medication right away because you have got TB - ANSB
Indurations less than 10 mm (non-immunocompromised) and 5 mm (immunocompromised)
is taken into consideration a terrible result after 48-seventy two hrs. Results greater indicate
publicity and viable TB contamination. Morse trying out (x-ray) can be wished.
A clients arterial blood gases are analyzed; pH 1.49, paO2 97 mmHg, HCO3- 22 mEq/L.
Which acid base stability disturbance does the nurse identify from these results?
A. Metabolic acidosis
b. Metabolic alkalosis
c. Respiratory acidosis
d. Respiratory alkalosis - ANSD
RAcidosis: paCo2 >forty five mmHg and RAlkalosis is paCo2 <35 mmHg. MAcidosis is
HCO3- is less than 22 mEq/L and MAlkalosis is HCO3- extra than 26 mEq/L.
A purchaser has lately been recognized with deep vein thrombosis of the proper leg. Which
of the following interventions of the nurse right now put into effect?
A. Elevating the foot of the mattress 6 inches
b. Placing ice packs on and under the right leg
c. Documenting the want for hourly calf measurements
d. Performing the want for hourly calf measurements - ANSA
DVT treatment includes bed relaxation, leg elevation, and alertness of warm, wet warmness.
Elevation decreases the venous pressure with relieves edema and ache. ROM cause reason
the thrombus to mobilize to the lungs causing PEs.
A nurse presents preparation to a patron with COPD about domestic oxygen therapy. Which
assertion made via the customer shows want for further coaching?
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