NCLEX

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Author:
dimacuha
ID:
181354
Filename:
NCLEX
Updated:
2012-11-13 01:57:36
Tags:
Saunders NCLEX LVN PN
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Description:
NOV 2
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  1. A licensed practice nurse (LPN) employed in the emergency department prepares to assist in treating a child with acetaminophen (Tylenol) overdose. The LPN checks the medication supply room, anticipating that which of the following medication will be prescribed?
    1. Vitamin K
    2. Protamine Sulfate
    3. Edetate calcium disodium (calcium EDTA)
    4. Acetylcysteine (Mucomyst)
    4. Acetylcysteine (Mucomyst)

    Acetylcysteine is the antitode for acetaminophen overdose
    . It is administerd orally with juice or cola or via nasograstric tube. Vitamin K is the antidote for warfarin sodium (Coumadin). Protamine sulfate is the antidote for heparin. Edetate calcium disodium is used in the treatment of leading poisoning.
  2. A client with Parkinsonian's disease is experiencing a parkinsonian crisis. The nurse would immediately place the client:
    1. In a bed with padded side rails, with limb restraints nearby
    2. In a room near the nursing station, which is near the code cart
    3. In a high-Fowler's position, with a nasogastric tube at the bedside
    4. In a quiet, dim room with respiratory and cardiac support available
    4. Quiet dim room with respiratory and cardiac support available

    Parkinsonian crisis can occur with emotional trauma or sudden withdrawal of medicaitons. The cleint exhibits severe tremors, ridgitdity, and bradykinesia. The client also displays anxiety, is diaphoretic, and has tachycardia and hyperpnea. The client should be placed in a quiet, dim room, and respiratory and cardiac support should be available.
  3. A nurse is assisting in planning the client assignments. Which of the following is the least appropirate assignment for the nursing assistant?
    1. Assisting a profoundly evelopmentally disabled child to eat
    2. Obtaining frequent oral temp on a client
    3. Accompanying a 51-yr old man discharged to home following bowel 8 days ago this his transportaion
    4. Collecting a urine specimen from a 70 year old woman admitted 3 days ago
    1. Assisting a profoundly developmentally disabled child to eat lunch

    The nurse must determine the most appropirate assignment based on the skills of the staff member and the needs of the client. In this case, the least appropriate assignment for a nursing assistant would be assisting with feeding a profoundly developmentally disabled child. The child is likely to have difficulty eating, and therefore a higher potential for complications such as choking and aspiration exist. The three remaining options include no data that indicate that these tasks carry any unforeseen risk.
  4. A nurse is preparing to perform chest physiotheraphy (CPT) on a client. Before determining the correct posiiton in which a place the client, the nurse must ascertain:
    1. Client's capability for lung expansion
    2. The lungs are involved
    3. The client's procedure for performing deep breathing techniques
    4. The proximity of the oxygen tank
    2. Lung areas involved

    • The goal of CPT is to mobilize secretions for improved respiratory fucntion. The nurse must determine which areas of the lungs should be targeted on this technique. The client's capability for lung expansion is secondary to the lung assessment. Deep breathing routines and oxygen use do not specifically relate to client positioning.
    • The nurse must determine which are of the lung should be targeted for technique
  5. A nurse is gathering data on a client with a diagnosis of tuberculosis (TB). Diagnostic test confirm this diagnosis?
    1. Chest x-ray
    2. Bronchoscopy
    3. Sputum culture
    4. Tuberclin skin test
    3. Sputum culture

    A definitive diagnosis of TB is confirmed through culture and isolation of Mycobacterium tuberculosis. A presumtpive diagnosis is made on the bases of tuberculin skin test, a suputum smear that is positive for acid-fast bacteria, a chest x-ray, and histologic evidence of granulomatous disease on biopsy

    Note the word "confirm"
  6. A nurse is gathering data from a client in crisis. When determining the client's perception of the precipitating event that led to the crisis, the most appropirate question to ask is?
    1. "With whom do you live?"
    2. "Who is available to help you?"
    3. "What leads you to seek help now?"
    4. "What do you usually do to feel better?"
    3. "What leads you to seek help now?"

    A nurse's initial task when gathering data from a client in crisis is to assess the individual or family and the problem. The more clearly the problem can be defined, the better the chance a solution can be found. Option 3 will assist in determining data related to the precipitating event that led to the crisis. Options 1 and 2 identify situation supports. Option 4 identify personal coping skills.
  7. A nurse develops a plan of care for a client following a lumbar puncture. Choose the interventions that will be included in the plan. Select all that apply:
    1. Monitor the client's ability to void
    2. Maintain the client in a flat position
    3. Restrict fluid intake for period of 2 hours
    4. Maintain the client on a nothing-per-mouth (NPO) status for 24 hours
    • 1. Monitor client's ability to void
    • 2. Maintain client in a flat position
    • 5. Monitor the client's ability to move the extremities
    • 6. Inspect the puncture site for swelling, redness, and drainage

    • Following a lumbar puncture, the client remains flat in bed for 6-24 hrs depending on the physician's order. A liberal fluid intake (not NPO status) is encouraged to replace cerebrospinal fluid removed during the procedure, unless contraindicated by the client's condition. The nurse checks the puncture site for redness and drainage, and monitors the client's ability to void and move the extremities.
    • -Give fluid to reduce headache - replace cerebrospinal fluid removed
  8. A nurse caring for a client with osteoarthritis. The nurse collects date, knowing that which of the following is a clinical manifestation associated with the disorder?
    1. Morning stiffness
    2. Positive rheumatoid factor
    3. An elevated sedimintation rate
    4. Dull aching pain in the affected joints
    4. Dull aching pain in the affected joints

    The stiffness and joint pain that occur in osteoarthritis diminis after rest and intesify after activity, and they may be aggravated by cold, damp weather. No specific laboratory finding are useful in diagnosing osteoarthritis. Dull, aching pain occurs in the affected joints and, unlike rheumatoid arthritis, systemic manifestation are absent and joint involvement is not symmetrical. Morning stiffness, and elevated sedimentation rate, and a positive rheumatoid factor occurs in rhumatoid arthritis
  9. A client is admitted to the hospital with a diagnosis of major depression. During the admission interview, the nurse determines that a major concrn is the client's altered nutrition related to poor nutritional intake. The appropirate initial nursing intervention related to this concern is:
    1. Weigh the client three times per week, before breakfast
    2. Explain to the client the importance of a good nutritonal intake
    3. Report the nutritional concern to the psychiatrist and obtain nutritional consult as soon as possible
    4. Offer the cient several small, frequent meals daily, and schedule brief nursing interactions with the client during these meals
    4. Offer the cient several small, frequent meals daily, and schedule brief nursing interactions with the client during these meals

    Change in appetite is one of the major symptoms of depression. Offering the client several small, frequent meals and the nurse's presence at the time to support, encourage, or perphaps even feed the client is the most appropriate intervention. A Client with depression experiences poor concentration and will not understand the importance of adequate nutritonal intake. Weighing the client does not address how to increase nutritional intake. Reporting the nutritonal problms to the psychiatrist is correct to some degree, but doesn't address how one might increase food intake.
  10. A client reports having had two bowel movements this morning and refuses a dose of docusate sodium (Colace). The nurse should plan to do which of the following next after doing the appropriate charting in the medication administration record?
    1. Notify the physician immediately
    2. Make a notation in the nurse's notes
    3. Make a note for the nurse on the evening shift to give the medicaiton
    4. Do nothing because no further action is required
    2. Make a notation in the nurse's notes

    If a client misses or refuses a dose of medication, the nurse should record in the nurse's notes the reason that the medication was not given. It is unnecessary to notify the physican immediately because of the nature of the medication and the client's reason for refusal. The licensed practicl nurse should, however, inform the registred nurse. Option 3 is incorrect because are not left for the nurse on the next shift to adminster because the client refusal. Option 4 is incorrect. An explanation of the missed dose should be recorded.
  11. Sutilains (Travase) is prescribed to treat the ulcer. The nruse avoids which action when performing the dressing change?
    1. Cleans the would with a sterile solution
    2. Places the sutilains in the refrigerator following use
    3. Moisten the wound with sterile normal saline and then applies the sutilains
    4. Dries the would and cover the sutilains applicaiton witha dry sterile dressing
    4. Dries the wound and cover the sutilains application with a dry sterile dressing

    The would should be cleansed with a sterile solution prior to treatment. The nurse then thoroughly moistens the wound with normal saline or sterline water, applies a thin film of sutilains extending 1/4 to 1/2 inch beyond the are to be debrided, and then applies a loose, thin dressing. The ointment should be refrigerated.

    Note the word AVOIDS
  12. A nurse in the emergency department is assisting in caring for a young female victim of sexual assualt. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withrawn, confused, and at times physically immoble. These behaviors are interpreted by the nurse as:
    1. Evidence that the client is a high suicide risk
    2. Indicative of the need for hospital admission
    3. Sign of depression
    4. Normal reactions to a devastating event
    4. Normal reaction to a devastating event

    The symptoms noted in the question indicate a normal reaction toa  very intensely difficult crisis event. Although the client's initial reaction may be predictive of later problems, they do not indicate an abnormal initial response.
  13. A nurse in the emergency department is assisting in caring for a young female victim of sexual assualt. The client's physical assessment is complete, and physical evidence has been collected. The nurse notes that the client is withrawn, confused, and at times physically immoble. These behaviors are interpreted by the nurse as:
    1. Evidence that the client is a high suicide risk
    2. Indicative of the need for hospital admission
    3. Sign of depression
    4. Normal reactions to a devastating event
    3. Provide oral hygiene care frequently

    Chemotheraphy may cause distortion of taste. Frequent oral hygiene aids in preserving taste function. Keeping a client NPO increases nutrional risk. Antiemeitic are used when nausea and vomiting are a problem. Parenteral nutrition is used when oral intake is not possible.
  14. A nurse is working with an older client and family about discharge following hospitalization. When initiating discussion with the group, the nurse understands that older persons would prefer to live:
    1. Independently, but close to their children
    2. In long-term care facilities
    3. With their children
    4. Alone
    1. Independently, but close to their children

    Most older people prefer to maintain their indepenence while having the resource of

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