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Nclex Review: Tough practice questions archer review 2 Questions With Complete Solutions
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Nclex Review: Tough practice questions archer review 2Questions With Complete Solutions
37-week neonate born at 1105. Weight at birth was 7 pounds 3
ounces (3316 grams). Head circumference 33 cm; chest
circumference 31 cm. The umbilical cord was clamped and cut,
revealing two arteries and one vein. Vigorous cry and movement
in all extremities were noted. Gluteal folds were symmetrical.
Breath sounds clear, and no grunting; pink body and cyanotic
extremities. Apical pulse was 119/minute; axillary temperature
96.5°F (35.8°C); respiratory rate was 50/minute. Pulse oximetry
95% on room air. APGAR at one minute was 9.
The neonate is at greatest risk for______due to the
neonates______
and___? Correct Answer hypoglycemia....cyanosis.......axillary
temp
The neonate is at the greatest risk for hypoglycemia, as
evidenced by cyanosis and low axillary temperature.
When the neonate is cold and demonstrating cyanosis, they use
more energy which burns glucose.
The nurse must consider performing a heel stick for a glucose
level and closely monitoring the neonate for hypoglycemia
manifestations, including jittery, weak, cry, hypotonia,
tachypnea, grunting, dyspnea, and tachycardia.
,Respiratory distress is excluded because the respiratory rate is
within normal 30-60/minute parameters, pulse oximetry is
optimal, and the lung sounds are clear.
The neonate was born at 37 gestational weeks, which is an early
term, and has an adequate weight.
The head circumference is within normal limits and excludes
micro- and macrocephaly. The average head circumference is 33
to 35 cm (13.2 to 14 inches), and the normal chest
circumference for a term newborn is 30-36 cm (12-14 in).
The gluteal folds are symmetrical, which excludes
developmental dysplasia of the hip. In DDH, they would be
asymmetrical.
The APGAR score, done one minute and five minutes after
delivery, is within the normal range. A score of 7-10 is
reassuring.
A vigorous cry is desired. Any cry that is high or low-pitched
requires follow-up.
A 30-year-old man comes into the clinic after being bitten by a
wild skunk approximately 12 hours ago. The nurse knows that
treatment for this client is likely to include:
Select all that apply.
Rabies immune globulin and vaccine
Wound cleansing with povidone-iodine or saline solution and
debridement
Treatment with an appropriate antibiotic
Suturing of the wound
Debridement of wound edges
Tetanus vaccine prophylactically Correct Answer Choices A,
B, C, E, and F are correct. Wild skunks have a high incidence of
rabies and should be considered rabid. The patient should
,receive rabies immune globulin and vaccine. The CDC
recommends the irrigation of the wound with povidone-iodine
since that solution is virucidal and may help prevent infection.
In the clinical judgment of the provider, saline can be safely
substituted for povidone-iodine. Debridement of the wound
edges may also help to prevent disease by cutting away tissue,
clots, and other material in the wound. Any bite wound should
be considered potentially infected, so an appropriate antibiotic
and tetanus prophylaxis will be administered.
Choice D is incorrect. The primary suturing of the injury is NOT
recommended in this case. The bite is older than 8 hours and
from an animal that has a high infection risk. Suturing the
wound will close any potential infectious agents into the injury
leading to an increased risk for infection.
A 63-year-old male presents with concerns about difficulty with
driving at nighttime. The client states, 'I feel like my vision is
blurred, and I cannot change it.' The client reports no pain in
either eye. He reports that this problem has 'gotten worse and
cannot drive anymore because it is hard to see at night' and it
started 'some time ago' and cannot pinpoint an exact start. The
assessment showed the pupils were equal, round, and briskly
reactive to light. They measured 3 mm. Slight opacity was noted
in both eyes. No loss in the visual fields.
Diagnostic: tonometry 20 mmHg out of 10 -21 mmhg
The nurse reviews the assessment findings
➢ Click to specify if the assessment findings are consistent with
cataracts or glaucoma. Each finding may support more than one
disease process
, Vision impairment worse at nighttime
Opacity in the eye
Blurred vision
Increase in intraocular pressure (IOP) Correct Answer The
client reported vision impairment worse at nighttime is a classic
manifestation of cataracts. This often is the symptom that
triggers a client to seek medical care because it makes driving
difficult. A client with cataracts has a problem with the eye lens
where opacities form. Cataracts may impact one or both eyes.
Blurred vision is a manifestation of both cataracts and glaucoma.
Glaucoma may cause a loss in peripheral vision. Ocular pressure
may be measured by tonometry and is often higher in the
morning when compared to the afternoon and evening hours.
Cataracts are a problem with the lens, whereas glaucoma is a
problem with increased intraocular pressure. The increase in
IOP is classically associated with glaucoma
Additional Info
Cataracts:
Cataracts may develop as an individual ages. Factors that
increase cataracts include UV exposure.
Trouble with discriminating colors and nighttime driving is
common.
Blurred vision that feels 'smudged.'
Age-related cataracts do not cause pain.
Glaucoma:
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