Increased myocardial oxygen use
a. Bronchodilators cause tachycardia
b. Decreases the amount of oxygen available for the rest of the body
c. HYPOkalemia and HYPERglycemia are caused by bronchodilator therapy
2. Recurring calf pain after walking one to two blocks that disappears with rest. Weak ...
LIVE REVIEW
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75-265 Questions
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100 questions a day starting in June
Nclex review book
NCLEX items will be
Knowledge based (to test recall and recognition) or Application (requiring use of nursing
knowledge to solve the problem)
Adverse effect of bronchodilator therapy
1. Increased myocardial oxygen use
a. Bronchodilators cause tachycardia
b. Decreases the amount of oxygen available for the rest of the body
c. HYPOkalemia and HYPERglycemia are caused by bronchodilator therapy
2. Recurring calf pain after walking one to two blocks that disappears with rest. Weak pedal
pulses, skin on left leg (lower leg) is shiny and cool to touch. Which nursing interventions?
a. Intermittent claudication (arterial insufficiency)
b. Position the leg dependently (put it down-blood will flow down)
c. Venous insufficiency (leg would go UP)
d. Arterial (letters go down in the capital A)
e. Venous insufficiency (put the legs UP like the letters in V)
Blood is only good for 4 hours (starting from when you leave the lab)
3. New tracheostomy, at home, the nurse recognizes a need for IMMEDIATE intervention when
the caregiver does which of the following?
, LIVE REVIEW
a. Life threatening!
b. Removes old tracheostomy ties before the new ones are secured (decannulate themself)
Maslow’s Hierarchy of Needs
Self actualization (not a lot of questions)
Self esteem (not a lot of questions)
Love and belonging
Safety and security
Physiological - COMES first, unless there is an immediate risk for suicide
ABC’s (not always airway first)
Nursing process (not always assess first)
Safety and risk reduction
4. Client sustained a c3 spinal cord injury. What finding should the nurse recognize as priority of
care?
● C4 and above affects the muscles for breathing
● C1/C2 on a ventilator immed.
● Respirations 10/min would be the priority
5. Nurse prepares an older adult for a scheduled colonoscopy. Which should be the nurse’s
INITIAL action?
● Place portable commode at bedside
● After physiological (prior to surgery so there are no physiological issues yet), next is
safety.
6. Client ER reports HX Gravida 3 Para 2. Initial Action after observing a presenting part?
● Prepare for delivery of the newborn in the ER.
● Client is already effaced and fully dilated.
● If you can DELEGATE something to a non licensed person, it's not your priority.
7. Nurse enters the room of a client who is at the foot of the bed lying on the floow. Nurses initial
action?
● Assess vital signs and LOC (before the person ended up on the floor, they had to be
conscious) FIRST.
Mass Casualties (Pg. 22)
Up and down traffic light is the order you save them.
Least Restrictive/invasive
Acute OVER Chronic (Acute always take priority with one exception, the chronic
condition has exacerbated to the point that it is life threatening ex. Status asthmaticus)
Stable vs. Unstable
Red immediate
Yellow delayed
, LIVE REVIEW
Green minor
Black (Require the most man power, equipment, supplies, etc.)
8. Four days after ventral hernia repair, a client who is obese and has a hx of COPD vomits and
reports severe abdominal pain. The oxygen sat is 90%. Which action should the nurse
implement first?
● Assess the surgical incision site.
● Client is OBESE so that puts them at risk for dehiscence and evisceration.
● 90% for a COPD client is acceptable.
9. Client who is 24 hours post acute MI and reports “I can't breathe now that I am lying down
after lunch” Nurse’s initial action
● Place client in high-fowler’s position
● Least invasive action
10. Nurse arrives at a work site explosion. Which client should be triaged first?
● Burns to the face and respiratory stridor (occlusion in airway)
● Fixed pupils and agonal respirations (random gasps of air) would get a black tag
11. Nurse is coordinating client care. Which client should the nurse delegate to the PN? A client
who
● Requires insertion of an indwelling urinary catheter
● NOTHING new/initial.
● Only reinforcement
12. An adolescent client was admitted 12 hours ago following mvc. Multiple skeletal fractures
were sustained. Client is in balanced suspension traction. Which assessment finding requires
immediate intervention by the nurse.
● Disorientation (change is mentation/LOC)***** potentially life threatening.
● Bloody drainage at the pin site is an expected finding
13. Nurse provides care for a client who is scheduled for ECT. Which medication should the
nurse withhold prior to therapy?
● Phenytoin (seizure medication) - You would not give this cause ECT causes seizures
● Atropine sulate (anticholinergic effects)
● Methohexital (short acting for sedation)
● Succinylcholine (paralytics)
14. A home health nurse is performing an admission assessment on a client who had a knee
arthroplasty one week ago. Which client statement should concern the nurse the most?
● I am so glad to be off those blood thinners
● Risk for DVT
● Should be on anticoagulants: 3-6 months
● Pillow should be under calf and heel
● No wheelchair. Needs crutches or walker
● Ibuprofen is an NSAID and increases risk for bleeding on top of the blood thinners the
patient is already consuming
15. Client has not voided 8 hours following the removal of an indwelling bladder catheter. What
should be the nurse’s initial action?
, LIVE REVIEW
● Perform bladder scan
16. Nurse provides care for a client who has a chest tube. The nurse notes the chest tube has
become disconnected from the chest drainage system. Which action should the nurse take?
● Immerse the end of the chest tube in a bottle of a sterile water
● Recreating a temporary water seal
17. Older adult dies from the complications of a CVA, the client’s partner is present at the
bedside. Which action should the nurse take?
● Stay with the partner at the bedside
18. Client dx with rheu arthritis, receive 3 months of methotrexate therapy. Which of the
following are adverse effects associated with the therapy? SATA
● WBC: 1,200 (neutropenic)
● Platelets: 5,000 (very low)
● Causes stomatitis (weight loss)
● Urine specific gravity: 1.003 (low) HIGH AND DRY not low for methotrexate
● Fever (greater than 101)
19. A nurse is organizing care for a group of clients. Which task should the nurse assign the
AP?
● Assist a client who is requesting a bedpan 1 day post of hysterectomy
● AP’s take routine vitals, do not take any vitals that are considered assessment vitals.
20. A nurse is observing a client attempt three point crutch walking (pg. 71). Which action
should be of concern to the nurse?
● The client moves leg with opposite arm
21. A school nurse observes several children playing on a playground. Which child should
concern the nurse most?
● Defect is ventricular septal (hole in the septum between the the ventricles)*surpassing
the lungs* blood that is oxygenated is going out to the patient's body. Kidneys may not
out as much urine.
● Right ventricular hypertrophy (big and large, won’t pump like it's supposed to. s/s of right
sided heart failure- jvd, dependant edema, ascites
● Overriding aorta (lays down between the right and left ventricle. Decreased cardiac
output cause its not sending blood out to the body)
● Pulmonic stenosis (between the right ventricle and the lungs, narrowed, some backflow
of blood)
● Tetralogy of Fallot - Squat
22. A client who is semi comatose after CVA, has a NG tube, and was started on TPN.
Which action should the nurse implement to prevent fluid volume deficit?
● Monitor blood glucose every 4-6 hr.
● Hyperglycemia - polyuria
● Osmotic diuresis
● Sliding scale insulin
Authoritative
Very little autonomy
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