The nurse is caring for a patient who has a pulse rate of 49 and has a blood pressure of 126/70. What should she ask?

Are you taking any medications?

RN on a med‑sur unit making assignments. Which tasks should the nurse delegate to the LPN

Vitals for pt 2 hrs after cardiac catheterization

When caring 4 the schizophrenic pt who is hallucinating, the best response by the nurse is

Acknowledge that the pt sees what he says, but remind him it's not real

A nurse is teaching about Plavix. Which should be included in teaching?

monitor for the presence of black, tarry stools

A nurse caring for a hospitalized 4-year-old boy with cerebral palsy should

be sure head is not tilted back when eating/drinking

Patient is taking levothyroxine, digoxin, and simvastin. Teaching is noted to be effective if?

Levothyroxine before breakfast and others at least an hour or more later

Which statement about hemophilia is true

It varies in severity based on % of clotting factor in body

The nurse is caring for a client who has suicidal thoughts. What should be the primary intervention by the nurse?

Create a safe environment for the client

What is Atopic Dermatitis triggered by?

food allergies and topical irritants

Pt is escalating as evidenced by rapid pacing and talking under his breath. The nurse should

Have the mental health tech take him for a walk

The nurse recognizes a need for further instruction when the HIV-positive patient says:

“My life is over. HIV and AIDS are the same thing.”

How is Scarlet Fever transmitted?

direct contact from a person with the dz and large droplets

What is the composition of purulent drainage?

white blood cells, debris, bacteria

A nurse is performing exam of client with PAD. Which is expected?

pallor w/ elevation of limb w rubor when limbs are dependent

When should a nurse consider culturing a wound?

When the surrounding area shows inflammation

When speaking with a hearing impaired patient, the nurse knows too:

face him and speak clearly in short sentences

In a patient with suspected appendicitis, which of these interventions are appropriate?

I.V. fluids; NPO, analgesics, Fowler’s position for pain.

Nurse is caring for a pt scheduled for a thyroidectomy. Instruction to include in preop care

Meds given 2 wks before surgery/reduce vascularity of gland

A nurse is cleansing a wound site. What intervention should be included?

Cleansing in a direction from the least contaminated area

When administering a prescribed expectorant to a pt with bronchiectasis, the RN anticipates:

reduced viscosity of respiratory secretions

studbud

NCLEX bound

100 termsStudBud Administration44 plays

Imported from external platform

Flashcards100 cardsFPractice quizPHost liveL

Questions 100

Answers

1
The nurse is caring for a patient who has a pulse rate of 49 and has a blood pressure of 126/70. What should she ask?
Have you had any fever?
Have you had any bleeding?
Do you have a history of COPD?
Are you taking any medications?
2
In assessing a patient, the nurse understands that an early sign of hypoxemia is:
cyanosis
hypotension
clubbing of nail beds
restlessness
3
RN on a med‑sur unit making assignments. Which tasks should the nurse delegate to the LPN
Administer unit packed red blood cells (RBCs) to cancer pt
Vitals for pt 2 hrs after cardiac catheterization
Instruct discharge pt on performance of wound care
Develop a plan of care for new pt who has pneumonia
4
Before leaving the room, should you encourage the Patient to ask for help?
True
False
5
Which of the following diagnoses is most appropriate for a patient with hypocalcemia?
airway clearance: ineffective
high risk for injury: bleeding
high risk for injury: confusion
constipation, bowel
6
Nurse is aware that severe dehydration associated with Diabetes Insipidus can lead to which electrolyte imbalance
Hypocalcemia
Hyperkalemia
Hypercalcemia
Hypernatremia
7
The nurse is caring for a patient admitted with suspected hyperparathyroidism. Which S&S would you NOT expect to see?
Increasing urine output
Lethargy and weakness
Neurologic irritability
Nausea and vomiting
8
The treatment for heroin abuse is
Librium
Gabapentin
Antabuse
Methadone
9
When caring 4 the schizophrenic pt who is hallucinating, the best response by the nurse is
Tell the pt that he knows that he is not really seeing anything !
Go along with what the pt reports seeing so as not to anger him
Acknowledge that the pt sees what he says, but remind him it's not real
I'm going to get a shot for you because it will stop these hallucinations
10
Pt has increased segs, increased bands, & decreased lymphocytes. Their infection is
Bacterial
Pt does not have an infection
Fungal
Viral
11
Autonomy is:
Equal resources and care
Being loyal, do no wrong
Promote good ethics
Respecting rights of others
12
A nurse is teaching about Plavix. Which should be included in teaching?
monitor for the presence of black, tarry stools
Instruct client to use electric razor
schedule a weekly PT test
Advise clients on foods with Vitamin K
13
A nurse caring for a hospitalized 4-year-old boy with cerebral palsy should
be sure head is not tilted back when eating/drinking
give the child a complete bed bath.
avoid discussing religious affiliation with his parents.
allow him to apply his new leg braces himself.
14
What substances are you at risk of losing when on diuretics?
Sodium and Potassium
Potassium and Chlorine
Chlorine and Sodium
Your Mojo
15
Your pt has a BUN of 6.4 and a urine specific gravity (USG) of 1.000. What is happening to this patient?
Fluid deficit
Fluid excess
These are normal lab values
Hyponatremia
16
When is the best time the nurse should start discharge planning for a patient?
Upon admission
Right before discharge
After the congestion is treated
When the primary care provider writes the order
17
A nurse is changing a dressing & providing wound care. Which activity should she perform first?
Assess the drainage in the dressing.
Slowly remove the soiled dressing
Put on latex gloves.
Wash hands thoroughly.
18
Which patient will require a negative pressure room
HIV
Tuberculosis
Pneumonia
End Stage COPD with PNA
19
Patient is taking levothyroxine, digoxin, and simvastin. Teaching is noted to be effective if?
All medications given together 1 hr after breakfast
All meds given at hs
Levothyroxine before breakfast and others at least an hour or more later
Levothyroxine is given with breakfast and other meds after.
20
A nurse manager showing favoritism by making unfair assignments is an example of
Bullying
Lateral violence
Cyberbullying
Incivility
21
Which statement about hemophilia is true
Bleeding is internal only
Hemophilia B is a deficiency of factor VII
It varies in severity based on % of clotting factor in body
People with hemophilia have a short life expectancy
22
Assessing a pt who has developed atelectasis postoperatively, the nurse will most likely find:
Dyspnea and pain
Decreased temperature
Severe cough and no pain.
A flushed face
23
The nurse should plan for all of the following except when caring for a pt w/borderline p/d
Make sure pt attends groups
Ensure that the patient adheres to all restrictions
Maintain a flexible schedule
Check for medication compliance with each med pass
24
The nurse is caring for a client who has suicidal thoughts. What should be the primary intervention by the nurse?
Provide the patient with music therapy
Make frequent rounds to the patients room
The nurse should take special care when administering medications
Create a safe environment for the client
25
The pH scale is a measure of what?
Density
Acidity
Speed of reaction
Temperature
26
What is a factor which can impair communication between the patient and the nurse?
the use of translator
patient's anxiety
allowing family members to be present upon patient request
effective pain medication use
27
The nurse notes macules, papules and vesicles on the trunk of the pt, what is the first action
Apply oatmeal based cream to affected area
Initiate airborne precautions
Initiate contact precautions
Administer acetaminophen
28
Nurse caring for pt who reports abruptly discontinuing prescribed levothyroxine. Monitor pt for
Sudden hypertension
Respiratory distress
Seizures
Extreme diarrhea
29
What is Atopic Dermatitis triggered by?
uncontrolled fever
food allergies and topical irritants
too much sponge-bob
Extremely hot baths
30
Pt is escalating as evidenced by rapid pacing and talking under his breath. The nurse should
Demand to know why he is pacing
Have the mental health tech take him for a walk
Administer the ordered prn for aggressiveness
Call for a takedown
31
The nurse recognizes a need for further instruction when the HIV-positive patient says:
“Drug protocols can keep me relatively healthy for years.”
“I can delay having full-blown AIDS if I change my ways.”
“My life is over. HIV and AIDS are the same thing.”
“I am aware that unsafe sex is a risk factor I ignored.”
32
patient must be competent/legal adult to give informed consent
False
True
33
. A nurse is assessing a patient’s skin. Which patient is most at risk for impaired skin integrity?
A patient who is afebrile
A patient with adequate skin turgor
A patient who is diaphoretic
A patient with strong pedal pulses
34
Working for the interest of your patient is your role is
standards of care
advocate
health care evaluator
caregiver.
35
How is Scarlet Fever transmitted?
Large crowds, rock-n-roll concerts
Not cleaning your car properly
Sharing your nursing books with your classmates
direct contact from a person with the dz and large droplets
36
What is the composition of purulent drainage?
mixture of serum and red blood cells
white blood cells, debris, bacteria
large numbers of red blood cells
clear, watery blood
37
A nurse is performing exam of client with PAD. Which is expected?
edema around the client's ankles and feet
pallor w/ elevation of limb w rubor when limbs are dependent
ulceration around the client medial malleoli
scaling eczema of the client's lower legs stasis dermatitis
38
The best approach by the nurse when dealing w/pt with OCD is to be accepting of ritualistic behaviors
True
False
39
Which is non-therapeutic communication?
Why did you take off your shoes?
What did you say? Can you do it? What's your opinion?
What you need is a husband-ectomy.
All of these.
40
When should a nurse consider culturing a wound?
When exudate is not present
When the patient is afebrile
When the tissue is clean and dry
When the surrounding area shows inflammation
41
A nurse is caring for a child with bronchitis. Which action should the nurse NOT take
Restrict fluid intake
Administer humidified O2
Place the child on contact precautions
Elevate HOB 30-40 degrees
42
When speaking with a hearing impaired patient, the nurse knows too:
face him and speak clearly in short sentences
shout
say everything twice
turn the volume up on the hearing aid
43
The patient with anemia usually presents with
Low energy level
Pink rosy skin
High energy level
Slower than normal respiratory rate
44
When assessing an infant admitted with pyloric stenosis, what would the nurse expect to see?
abdominal distension
projectile vomiting
increased urine output
watery diarrhea
45
When ambulating a patient who has a weak right side, you should stand
in back of the patient
on the patient's left side
on the patient's right side
in front of the patient
46
In a patient with suspected appendicitis, which of these interventions are appropriate?
Give I.V. fluids, NPO, and give an enema before surgery
I.V. fluids; NPO, analgesics, Fowler’s position for pain.
Give I.V. fluids, NPO, and apply heat to his abdomen.
47
Nurse is caring for a pt scheduled for a thyroidectomy. Instruction to include in preop care
Keep a food diary for 2 weeks prior to surgery.
Avoid salt for 2 weeks prior to surgery.
Meds given 2 wks before surgery/reduce vascularity of gland
Preop meds include drugs to increase vascularity of gland.
48
Man who has been caring for his mom can't move his legs suddenly & is unable to care for her
Compensation
Conversion
Displacement
Sublimation
49
A nurse is cleansing a wound site. What intervention should be included?
Allowing solution to flow from most to least contaminated
Utilizing clean gauge and clean gloves to cleanse a site
Cleansing in a direction from the least contaminated area
Scrubbing vigorously when applying solutions to the skin
50
When administering a prescribed expectorant to a pt with bronchiectasis, the RN anticipates:
cough suppression
bronchial dilation
reduced viscosity of respiratory secretions
decreased production of respiratory secretions
51
Closed ended questions are the best to use when interviewing a patient
True
False
52
A LPN is caring for a pt with a dressing over a wound that has never been changed. The LPN should
Change the dressing so she can assess the wound.
Administer an analgesic 30 minutes after a dressing change.
Administer an analgesic 30-45 min. before a dressing change.
Culture the wound if wound exudate is present.
53
A patient who is FWB can
walk in the hallway
Transfer independantly
stand on both legs
stand on one leg
54
Upon initial assessment, the nurse finds s/s indicating Epiglottitis. Priority action is?
Initiate chest compressions
Document as normal finding
Palpate the carotid pulse
Notify MD immediately
55
The nurse is aware of all of adverse effects of fluticasone propionate except
Epistaxis
Digital Clubbing
Headache
Oral Trush
56
Nurse sees pt laughing at the wall. It is appropriate to ask the pt if he is seeing anything on the wall
True
False
57
Your patient is compulsively washing his hands when entering the room. What action do you take?
Ask to immediately stop hand washing
Allow to complete and then begin teaching
While pt. washing hands introduce alternatives in washing
Ask pt. to describe events that precipitated the washing
58
A CF Pt my have all of the following except
tendency for status asthmaticus
excessive viscous pulmonary secretions
Malnutrition
Meconium ileus (bowel obstruction)
59
Observations to report when a patient is being admitted include:
All of the above
Pressure ulcers
Rashes
Hearing problems
60
Pt is on haldol. Develops cogwheel rigidity. Nurse anticipates what medication being ordered?
sertraline (Zoloft)
risperidone (Risperdal)
benztropine (Cogentin)
diphenhydramine (Benadryl)
61
The nurse caring for the patient with serum sickness should anticipate
Daily weights
Administering acetaminophen
Restricting fluids
giving a blood transfusion
62
A nurse is speaking with the mother of a 6-yr-old. Which of the following statements by the mom should concern the nurse
"Sometimes my child acts bossy with his friends."
"My child often cheats when we play board games."
"The teacher says my child has to squint to see the board."
"My child has recently lost both front top teeth."
63
Agglutination is
Clumping of particles
Formation of antibodies
Destruction of particles
Creation of particles
64
Which sign indicates a patient with SIADH may be experiencing complications?
Polyuria
Weight loss
Jugular Venous Distention
Tetanic Contractions
65
Lightening is a term used to describe when
The fetal head descends into true pelvis
Breathing becomes more difficult during labor
Less pressure is placed on the bladder
Membranes rupture
66
The nurse states, "What actions do you feel you should take?". This therapeutic communication example is known as
Offering self
Giving recognition
Reflecting
Restating
67
The first step in assessing a patient in cardiac arrest is to:
obtain a SAMPLE history
attach the AED
verify pulselessness and apnea
perform a focused physical exam
68
Which isolation precautions should be implemented for a patient with active tuberculosis?
airborne
contact
neutropenic
droplet
69
The nurse is caring for a patient with diabetes. Which task will the nurse assign to the nursing assistive personnel?
Determining aspiration risk
Making an occupied bed
Providing nail care
Teaching foot care
70
The LPN is caring for a pt who is bleeding. To control bleeding, she would apply a __ dressing.
pressure
alginate
hydrocolloid
foam
71
When fluid is present in the alveoli:
hypoventilation occurs.
the patient is in heart failure.
alveoli collapse and atelectasis occurs.
diffusion of oxygen and carbon dioxide is impaired.
72
The nurse is performing a respiratory assessment. Which best supports the nursing diagnosis of ineffective airway?
Respiratory rate of 24 breaths/min
Basilar crackles
Oxygen saturation of 92%
Presence of greenish sputum
73
When you are describing an injury to the right chest, right refers to
Your right, while facing away from the patient
The patient's right, regardless of position
Your right, while in a prone position
Your right, while facing the patient
74
When working with a disoriented patient, you should:
try to make the patient understand you
ask the patient if they remember you or know who you are
avoid distractions of noise or activity during communication
get as close to the patient as possible when talking
75
What is the function of the hypothalamus?
Regulates calcium in blood and bones
Memory storage
Hunger/thirst, sexual activity,temp,heart rate,shivering etc
Promotes safety and inhibiton
76
Nurse is caring for patients at risk for sepsis. Which of the following is at the highest risk?
Pernicious anemia
Pericarditis
Patient with tattoos
Post-kidney transplant
77
A nurse is assessing the developmental level of a 3yr old. Which of the following does the nurse expect to observe?
Pouring own drink
Drinking from a cup
Slicing an apple
Using a knife and fork
78
What is HIPAA?
Health Insurance People are Actually Awesome
Help Iris Peter and Alex Arrested
Helpful Interested People are At Attention
Health Insurance Portability and Accountability Act
79
A nurse is aware that many pts with ostomies have an altered self-image. What might this cause?
Irrational anger
Nonadherence to diet
Sexual dysfunction
Self-care deficits
80
What is dysphagia?
Difficulty coughing
Difficulty breathing
Difficulty swallowing
Difficulty speaking
81
The second heart sound (S2) occurs when
The aortic and pulmonic valves close
The mitral and tricuspid valves close
Systole begins
There is rapid ventricular filling
82
Positive Trousseau and Chvostek signs are indicative of hypercalcemia
True
False
83
A pt with AIDS is experiencing fever with night sweats. A suggestion the nurse could make is to
take aspirin if awakened in the night.
limit fluid intake after supper.
drink all liquids in the morning.
keep liquids at the bedside to drink.
84
There is a risk of countertransference when caring for the avoidant personality client
True
False
85
You are making the assignment, which patient should be assigned to the unlicensed assistive personnel?
A pt with DM who needs insulin daily
A patient who requires twice-daily dressing changes
A patient who is on a bowel management program and needs an enema daily
A patient who requires a 24-hour urine collection
86
When providing endotracheal suctioning, the nurse should take which action?
Remove the suction catheter using a rotating motion
Suction the patient's endotracheal tube every 2 hours
Suction the endotracheal tube using clean technique
Suction the mouth prior to suctioning the endotracheal tube
87
When assessing the respiratory system of an older pt, which finding needs immediate action?
Dry mucous membranes
Weak cough effort
Barrel-shaped chest
Bilateral crackles at lung bases
88
A nurse is caring for a 5yr old who has a fracture of the femur. The nurse provides which activity for the child?
Crayons and colouring books
An iPod
Large picture books
A laptop
89
Viral load testing is used to
Determine if the pt has acquired an opportunistic infection
Determine the patient's response to antiretroviral therapy
See if a post on facebook has gone viral
Determine the CD4 T-lymphocyte count
90
Excessive release of too much ADH results in
Edema
Dehydration
Polyuria
Polydypsia
91
Which of the following should the nurse utilize when caring for a pt with dissociative fugue?
Use the flooding technique to remind client of his past
Make decisions for the client regarding every day activities
Work w/client to recognize stressors that bring on different personalities
Work with the client on grounding
92
REVIEW: LOC shows your patient to be unconscious. Next, you should...
perform a rapid medical assessment
obtain vital signs
obtain a SAMPLE history
check the ABCs
93
When does GERD occur?
taco tuesday
Only when you are diabetic
When gastric acid damages the esophageal mucosa
When you eat your feelings after a bad test grade
94
A serous exudate is best described as a:
thick, greenish material containing microbes.
thick, sticky, cloudy secretion.
brownish, clotted material.
thin, watery, colorless exudate.
95
The step after inspection when assessing the abdomen is
Auscultation
Percussion
Palpation
Deep palpation
96
The nurse clarifies that the first stage of wound healing is:
reconstruction
inflammation
maturation.
proliferation.
97
What is the most accurate definition of a wound?
any trauma resulting in serious damage and pain
a disruption in normal skin and tissue integrity
a change in the function of internal organs
any injury that results in changes in nervous tissue
98
What should a LPN expect when assessing a patient’s respirations that indicate impending death?
Deep, clear breath sounds
Noisy, wet-sounding respirations
Even, unlabored respirations
Shallow, clear breath sounds
99
A nurse documents a closed wound on a patient chart. Which is an example of a closed wound?
incision
puncture wound
abrasion
ecchymosis
100
When caring for a pt from another culture, what is the best communication strategy to use?
Stereotyping the patient within his or her culture
Considering the context of the patient’s background
Using a cultural joke to break the ice
Assuming the patient or the family member speaks English

NCLEX bound Flashcards | StudBud