NCLEX RN Practice Test 1,2,3,4,&5

21 cards   |   Total Attempts: 192
  

Cards In This Set

Front Back
Arrives at ED with chest pain; priority action? A. HxB. ECGC. VSD. Chest exam with auscultation
C. Careful assessment of VS
Pneumonia, discharge instructions; what NOT to do? A. May resume normal activities as tolerated but should avoid physical exertion and get adequate rest B. Resume normal diet with emphasis on nutritious, healthy foodsC. Stop oral antibiotics when symptoms completely resolveD. Continue use of incentive spirometer to keep airways open and free
C. Stop oral antibiotics when symptoms completely resolve * Finish the whole prescription of antibiotics even if symptoms are resolved
Vietnamese patient terminal stages of lung cancer. Family members are in the room around the clock performing unusual rituals and bringing ethnic foods. What action should the nurse take? A. Restrict visiting hours and ask the family to limit visitors to two at a time B. Notify visitors with a sign on the door that patient is limited to clear foodsC. If possible, keep the other bed in the room unassigned to provide privacy and comfort to the family D. Contact the physician to report the unusual rituals and activities
C. If possible, keep the other bed in the room unassigned to provide privacy and comfort to the family
The charge nurse on the cardiac unit is planning assignments for the day. Which of the following is the most appropriate assignment for the float nurse that has been reassigned from labor and delivery? A. 1 week post-op CABG patient, who is being evaluated for placement of a pacemaker prior to dischargeB. Suspected MI patient on telemetry, just admitted from the ED and scheduled for angiogram C. Patient with unstable angina being closely monitored for pain and medication titration D. Post-op valve replacement patient who was recently admitted to the unit because all surgical beds were filled
A. One week post-op CABG patient, who is being evaluated for placement of a pacemaker prior to discharge * Likely to require routine care
8 year old child with Type I DM and his mother receiving diabetes education; purpose of Glucagon? A. Glucagon enhance the effects of insulin in case the blood sugar remains high one hour after injection B. Glucagon treats hypoglycemia resulting from insulin overdoseC. Glucagon treats lipoatrophy from insulin injectionsD. Glucagon prolongs the effect of insulin, allowing fewer injections
B. Glucagon treats hypoglycemia resulting from insulin overdose * Glucagon is given to treat insulin overdose in an unresponsive patient * Following Glucagon administration, the patient should respond withing 15-20 minutes at which time oral carbohydrates should be given
Correct placement of the conductive gel pads? A. The left clavicle and right lower sternum B. Right of midline below the bottom rib and the left shoulderC. The upper and lower halves of the sternum D. The right side of the sternum just below the clavicle and left of the precordium
D. The right side of the sternum just below the clavicle and left of the percordium
Abdominal pain; "clicks and gurgles" in all four quadrants as well as "swishing or buzzing" sound heard in 1 or 2 quadrants. Statement is correct? A. The frequency and intensity of bowel sounds varies depending on the phase of digestionB. In the presence of intestinal obstruction, bowel sounds will be louder and higher pitchedC. A swishing or buzzing sound may represent the turbulent blood flow of a bruit and is not normal D. All of the above
D. All of the above * The gurgles and clicks described represent normal bowel sounds, which vary with the phase of digestion
* Intestinal obstruction causes the sounds to intensify as the normal flow is blocked by the obstruction * The swishing and buzzing sound of turbulent blood flow may be heard in the abdomen in the presence of abdominal aortic aneurism (always be considered abnormal)
ED, splashed concentrated household cleaner in his eye; priority nursing action? A. Irrigate the eye repeatedly with normal saline solution B. Place fluorescein drops in the eye C. Patch the eye D. Test visual acuity
A. Irrigate the eye repeatedly with normal saline * The irrigation should be continued for at least 10 minutes
Has had hip replacement; concerned about which finding? A. Complaints of pain during repositioning B. Scant bloody discharge on the surgical dressing C. Complaints of pain following physical therapy D. Temperature of 101.8 F (38.7 C)
D. Temperature of 101.8 F
Uncontrolled seizure disorder; actions to take in the event of a seizure. NOT be included? A. Notify the physician B. Restrain the patient's limbsC. Position the patient on his/her side with the head flexed forward D. Administer rectal diazepam
B. Restrain the patient's limbs
Four patients, highest priority? A. Patient with low-grade fever, headache, and myalgias for the past 72 hours B. Patient who is unable to bear weight on the left foot, with swelling and bruising following a running accident C. Patient with abdominal and chest pain following a large, spicy mealD. Child with a one-inch bleeding laceration on the chin but otherwise well after falling while jumping on his bed
C. Patient with abdominal and chest pain following a large, spicy meal * Patient's with trauma, chest pain, respiratory distress, or acute neurological changes are always classified number one priority
A patient is admitted to the hospital with a calcium level of 6.0 mg/dL. Which of the following symptoms would you NOT expect to see in this patient? A. Numbness in hands and feetB. Muscle cramping C. Hypoactive bowel soundsD. Positive Chvostek's sign
C. Hypoactive bowel sounds * Normal serum calcium is 8.5-10 mg/dL * Hypocalcemia: hyperactive bowel sounds, abdominal cramping, diarrhea, numbness in hands and feet, and muscle cramps * Positive Chvostek's sign
A nurse cares for a patient who has an NG tube attached to low suction because of a suspected bowel obstruction. Which of the following arterial blood gas results might be expected from this patient?A. pH 7.52, PCO2 54 mmHg B. pH 7.42, PCO2 40 mmHgC. pH 7.25, PCO2 25 mmHgD. pH 7.38, PCO2 36 mmHg
A. pH 7.52, PCO2 54 mmHg * At risk of metabolic alkalosis as result of loss of hydrochloric acid in gastric fluid
Patient admitted to the hospital for routine elective surgery. Included in the list of current medications is Coumadin (warfarin) at a high dose. Concerned about the possible effects of the drug, particularly in a patient scheduled for surgery, the nurse anticipates which of the following? A. Draw a blood sample for prothrombin (PT) and international normalized ratio (INR) levelB. Administer vitamin KC. Draw a blood sample for type and crossmatch and request blood from the blood bank D. Cancel the surgery after the patient reports stopping the Coumadin one week previously
A. Draw a sample for PT and INR level * Coumadin is to inhibit clotting * PT and INR to determine the patient's anti-coagulation status and risk of bleeding
The following lab results are received for a patient. Which of the following results are abnormal? SATAA. Hemoglobin 10.4 g/dLB. Total cholesterol 340 mg/dLC. Total serum protein 7.0 g/dLD. Glycosylated hemoglobin A1C 5.4%
A&B * Normal hemoglobin = 12-16 g/dL* Total cholesterol = 200 mg/dL or below