NCLEX-PN REVIEW (DELMAR'S NCLEX-PN REVIEW)
2024/2025 | ACCURATE REAL EXAM
QUESTIONS WITH VERIFIED ANSWERS |
EXPERT VERIFIED FOR A GUARANTEED PASS |
LATEST UPDATE
,The nurse is instructing a client with Addison's disease about a newly prescribed
medication, fludrocortisone acetate (Florinef). Which statement by the client indicates a
need for further teaching? - ✔✔ANSW✔✔.."I will be glad to gain weight."
Rationale: The client should notify the health care provider of weight gain. The client
should take oral drugs with food or milk. The client should wear a Medic-Alert bracelet.
Fludrocortisone acetate (Florinef) should not be stopped abruptly but should be tapered
down.
The nurse is caring for a client who had a tracheostomy tube inserted 1 week ago. The
client begins to cough vigorously, and accidental decannulation of the tracheostomy
tube occurs. Which action should be the nurse's immediate response? -
✔✔ANSW✔✔..Replace the tracheostomy tube.
Rationale:
If decannulation of a tracheostomy tube occurs 72 hours after surgical placement of the
tracheostomy, the nurse prepares to replace the tube. The nurse also calls for help
immediately. The nurse extends the client's neck and opens the tissues of the stoma to
secure an airway. With the obturator inserted into the new tracheostomy tube, the nurse
quickly and gently replaces the tube and immediately removes the obturator. The nurse
checks for airflow through the tube and for bilateral breath sounds. If unable to secure
the airway, the nurse notifies the respiratory therapist and attempts to ventilate the client
with a bag-valve mask (resuscitation bag) while waiting for help. If the client is in
distress and further attempts to secure the airway fail, the nurse calls the resuscitation
team, including an anesthesiologist, for assistance and calls a code if necessary.
The nurse working in a pediatric clinic is preparing to administer childhood vaccinations
to a 15-month-old child. Which vaccine should be added to the child's routine
immunizations at this time because the child is older than 12 months of age? -
✔✔ANSW✔✔..Varicella
Rationale:
Varicella vaccine is recommended at any visit at or after age 12 months for susceptible
children (i.e., children who lack a reliable history of chickenpox and have not been
vaccinated). The other vaccines are administered on or before age 1 year.
The nurse enters a client's room to check the client who began receiving a blood
transfusion 45 minutes earlier. The client is flushed and dyspneic. The nurse listens to
the client's lung sounds and notes the presence of crackles in the lung bases. The client
states that she was just going to ring the call bell for the nurse. The nurse determines
that this client is most likely experiencing which complication of blood transfusion
therapy? - ✔✔ANSW✔✔..Fluid (circulatory) overload
Rationale:
,With fluid (circulatory) overload, the client has the presence of crackles in the lungs in
addition to dyspnea. Hypovolemic shock (restlessness, increased pulse, decreased
blood pressure) is not likely to occur in a client receiving fluids. An allergic reaction,
which is one type of blood transfusion reaction, would produce symptoms such as
flushing, dyspnea, itching, and a generalized rash. With bacteremia, the client would
have a fever, which is not part of the clinical picture presented.
A 10-year-old child with asthma is treated for acute exacerbation. Which finding would
indicate that the condition is worsening? - ✔✔ANSW✔✔..Decreased wheezing
Rationale:Decreased wheezing in a child who is not improving clinically may be
interpreted incorrectly as a positive sign, when in fact it may signal an inability to move
air. A "silent chest" is an ominous sign during an asthma episode. With treatment,
increased wheezing may actually signal that the child's condition is improving. Warm,
dry skin indicates an improvement in the condition because the child is normally
diaphoretic during exacerbation. The normal pulse rate in a 10-year-old is 70 to 110
beats per minute.
The nurse is assigned to assist in caring for a client with a chest tube drainage system.
In planning for the client, the nurse makes certain that what equipment is available, in
the event that the drainage system needs to be changed? - ✔✔ANSW✔✔..Rubber-shod
clamps
Rationale:
If the drainage system needs to be changed, the registered nurse will use rubber-shod
clamps to clamp the tube near the client's chest while the drainage system is changed.
This procedure is done quickly and with the assistance of another nurse. The clamps
are removed immediately after reconnection of the new drainage system. Agency
procedure regarding clamping chest tubes is always followed, and a health care
provider's prescription for clamping the tube may be required. If clamps must be used,
the best time to apply them is after expiration. An occlusive dressing such as a
petrolatum (Vaseline) gauze dressing is used when a chest tube is removed. Options 2
and 4 are not needed for changing a drainage system.
A client has been receiving parenteral nutrition at 125 mL/hr for 5 days. On data
collection, the LPN notes bilateral crackles and 2+ pedal edema and that the client has
gained 3 pounds in 5 days. Which would be appropriate as the initial nursing action? -
✔✔ANSW✔✔..Notify the registered nurse of the findings.
Rationale:
The client is showing signs of fluid retention and possible excess fluid intake. Crackles,
edema, and weight gain signify fluid shifts from intravascular spaces to the interstitial
spaces. The problem may or may not be related to the parenteral nutrition. Other
possible causes of fluid retention include impaired respiratory and cardiovascular
function, impaired kidney function, or a combination of factors. The nurse needs to
notify the registered nurse of the findings. The registered nurse will then notify the
, health care provider for further prescriptions. Option 2 will have little, if any, effect on
peripheral edema and weight gain. Option 3 infers that a diuretic will help the situation,
and it is possible that the health care provider will prescribe a diuretic; however, the
health care provider needs to be aware of the change in the physical condition of the
client. The nurse should not increase or decrease the rate of parenteral nutrition
infusions without a health care provider's prescription to do so.
The nurse notes this rhythm on the client's cardiac monitor. The nurse next reports that
the client is experiencing which heart rhythm? Refer to figure. - ✔✔ANSW✔✔..Atrial
fibrillation
Diagram of normal sinus rhythm as seen on ECG. In atrial fibrillation the P waves, which
represent depolarization of the top of the heart, are absent
Do not delegate what you can EAT - ✔✔ANSW✔✔..Don't delegate what you can:
E- Evaluate
A- Assess
T- Teach
*As a PN go to the RN and the RN will contact the HCP
Follow up with performed task that has been delegated.
Addisons: Down, Down, Down, Up, Down
Cushings: Up, Up, Up, Down, Up - ✔✔ANSW✔✔..*Addisons*: Hyponatremia,
Hypotension, Decreased blood volume, Hyperkalemia, Hypoglycemia
*Cushings*: Hypernatremia, Hypertension, Increased Blood Volume, Hypokalemia,
Hyperglycemia
No Pee, No K - ✔✔ANSW✔✔..Don't give potassium without adequate urine output.
(Adult: 30 ml/hr Child: 20-30 ml/hr)
Monitor I&O
Ele*V*ate *V*eins & D*A*ngle *A*rteries for - ✔✔ANSW✔✔..Better perfusion so as not
to have impaired tissue perfusion
*A*rteries
*V*eins - ✔✔ANSW✔✔..*A*way from the heart
To the heart
HPV - ✔✔ANSW✔✔..virus has ben linked to cervical cancer
1 gram - ✔✔ANSW✔✔..1 ml
Cholesterol Levels - ✔✔ANSW✔✔..LDL: lower than 130mg/dL
HDL: 30-70 mg/dL
