NCLEX PN Questions And Answers 100% Correct Reduce symptoms of Raynauds disease? - Wearing gloves when handling frozen food What is Raynauds disease? - reduced blood flow due to spasm of arteries of the feet and hands When removing a chest tube, what should you instruct the patient to do? - hold breathe and bear down When you notice blanching, coldness and edema at the IV site, what should you do? Remove the IV What is considered a normal Blood Glucose level? - 70-100 What PPE to use for MRSA patient? - Gloves Gown Goggles Mask What is an EARLY sign of digoxin toxicity, from the drug digoxin? - Anorexia What are normal Magnesium levels? - 1.6 - 2.6 mg What are signs of elevated magnesium levels? - Drowsiness Sedation Lethargy Muscle weakness Areflexia What is Areflexia? - Absence of the reflexes What position should you place a patient with acute epiglottitis? - Sit upright What position to use for Soapsuds enema? - Left side SIMS position What is the 1st step when looking into the NCLEX exam? - Step 1: Access the NCSBN website at www.ncsbn.org (Obtain info for international nurses) For state licensing? - Contact the state in which you are taking the NCLEX in and determine specific requirements for that state
What is the process for sending the state official documents? - They must come from the "Licensing Authority" Is the NCLEX exam administered in other languages? - No (ONLY in English) What is your Initial response after a patients trach tube becomes dislodged? - Use a manual BVM/resuscitation device? What is the "immediate" action to take after a heart failure patient presents with shortness of breath/dyspnea? - Raise the head of the bed How soon after the administration of nitroglycerin should the patient see relief? - 5 mins (Burning sensation/vertigo are common side effects) What is a concern when a patient is taking Warfarin? - Bleeding easily (Educate patient on straight razor use) What is Dystocia? - Abnormal labor or childbirth What is the 1st step in the Nursing process? - Data collection What is the 2nd step in the Nursing process? - Planning What is the 3rd step in the Nursing process? - Implementation What is the 4th step in the Nursing Process? - Evaluation What is the medication "Tigan" used for? - Nausea and Emesis Iron supplements should be taken with what? - Vitamin C rich juices (Tomato juice, Orange juice) When noticing that the fundus of a postpartum patient is soft and spongy, what should you do? - Massage the fundus gently until it is firm Drugs that end in "lol" are normally used for what? - Beta Blocker (for hypertension) ("Lo" Lowers the BP) What OTC tabs should patients not take with medication? - Antacids tabs (effects the absorption of the med) Which tabs should not be crushed? - Enteric Coated/sustained release tabs Can nurses adjust or change a patients medication? - NO (only the Doctor can do this)
T/F Patients should consult a doctor before taking OTC or any herbal preparations? - True Can Abandonment charges be filed against nurses who walk out if staffing is inadequate? Yes Can nurses refuse to float? - No, unless their Union contract states they only work in a specific area Do Nurses need to get their own Insurance against malpractice? - YES Who issued the Patients Bill of Rights? - American Hospital Association What is habeas Corpus, and can a mentally ill patient request it? - Requesting a release from care/Yes they can T/F Catholics, Christians and Jehovah witness are the only religions that allow organ donations? - True T/F Orthodox Judaism may allow organ donation with the Rabbis approval? - True What are Incident reports used for? - Identifying risk situations and Improving care Do Incident reports get filed in the Patients record? - No What are the components of a medication prescription? - Date/Time Med name Dosage Route Frequency Signature How is a Telephone medication order abbreviated? - t.o Can a nurse sign or be a witness to a signature for a "Living Will" for her patient? - No, must be signed by someone who isn't staff or be notarized What is managed care? - Strategies used to reduce the cost of health care. T/F Case management involves collaboration with an Interprofessional health care team? TRUE What are the 5 types of leaders? - 1) Autocratic-Dominates the group, maintains strong control and address problems with clearly defined tasks. 2) Democratic-Participative style, all members of the team should have input. 3) Laissez-faire-Passive, inactive and delegates responsibility to the group (Lazy)
4) Situational-Leads based on current circumstance/situation. 5) Bureaucratic-Leader believes that the team is motivated by EXTERNAL forces, relies on policies/procedures for decision making. What is Inter-personal and Intra-personal conflict? - Intra-within a person Inter-within the group When does discharge planning begin? - When patient is admitted What is Priority 1, 2, and 3 of the Emergency room triage? - Priority 1-Emergent (Chest pain, respiratory distress, major arterial bleed, chemical splashes to the eye) Priority 2-Urgent (Not life-threatening, unless not treated within 1-2 hours, eval every 3060 mins) Priority 3-Minor issues, eval every 1-2 hours) What is Phlebitis? - Inflammation of a vein What id Third Spacing? - The accumulation of extracellular fluid in a body space due to disease or injury What does Extracellular mean? - Fluid outside the cells What does Interstitial mean? - Fluid between the cells and the blood vessels Which population is at "higher" risk for fluid related problems? - infants and Elderly Water lost through the skin and lungs (expired air) is called? - Insensible loss What is Hypokalemia? - A potassium level lower than 3.5 mEq/L Can potassium supplement be taken on an empty stomach? - No, causes nausea and emesis What else should be performed when a patient is receiving potassium supplements through IV? - Cardiac monitoring Can potassium be administer via IV push? - No, only IV or orally What level is the sodium when a patient has hyponatremia? - Sodium level will be less than 135 What is the antidote for magnesium overdose? - Calcium gluconate Why is a patient with a nasogastric suction at risk of potassium deficit? - Potassium rich fluids are lost through GI suctions Patients with Addisons disease are at risk for what? - Hyperkalemia
(High potassium) When a patient has hyperkalemia, what can you expect to see on an EKG? - Narrow peaked T waves What is an insensible fluid loss? - Cant be measured (Through skin and lungs) Can a patient with a fast respiratory rate be susceptible to "Insensitive" fluid loss? - Yes (From the lungs) What 4 patients may be at risk for "Third Spacing"? - -Renal failure -Sepsis -Liver (cirrhosis) -Burns (major) What patient is least likely to have Third Spacing? - Diabetic What is the primary buffer system in the body? - Carbonic acid-bicarbonate (HCO 3 -) What does the respiratory rate do with Acidosis and Alkalosis? - Acidosis-RR increases Alkalosis-RR decrease What should you monitor for in a patient with severe diarrhea? - Metabolic aCidosis What should you monitor for in a patient with severe vomiting? - Metabolic alKalosis What is the Allens test? - Applying pressure to the arteries in your wrist How soon should blood return to the hand after the Allen test? - 6-7 seconds (If it takes longer, use a different hand for blood draw) How long should you hold pressure on a draw site if patients are taking anticoagulants? - 510 mins (3-5 mins for a coagulation defect) In Acidosis the pH is up or down? - Down In Alkalosis the pH is up or down? - Up Can you use the arm that has an infusion going for blood draws? - No, it can give inaccurate results (Try and draw blood 1 hour prior to intermittent heparin)
Clenching/unclenching of the fist during a blood draw can cause what inaccurate result? Potassium level If the aPTT value is prolonged longer than ___ seconds in a patient receiving heparin, initiate bleeding precautions? - 90 seconds If the PT value is longer longer than ___ seconds in a patient receiving warfarin, initiate bleeding precautions? - 30 seconds What should you monitor in a patient receiving Chemo due to the risk of Thrombocytopenia? - Platelet count What is the normal RBC for a male and female? - Female 4.0 - 5.5 Male. 4.5 - 6.2 If a patient is experiencing dyspnea and has an elevated BNP, what is the diagnosis? - Heart failure (If the BNP is normal, the the dyspnea is a result of respiratory distress) In "acute" pancreatitis the amylase levels may exceed how many times the normal limit? - 5 times (Levels start rising around 6 hours of the onset of pain, peaks at 24 hours) In "chronic" pancreatitis the serum amylase levels may increase how many times the normal limit? - 3 times (normally does not exceed 3) True/False Patients with liver disease have prolonged clotting times? - True How long should the patient fast before a glucose study? - 8-12 hours What is the normal WBC count? - 4,500 - 11,000 What is the normal specific gravity of urine? - 1,016 - 1,022 What is the preferred source of energy? - Carbs (Milk, grains, fruits and veggies) Not enough essential fats in the diet can lead to what? - Amenorrhea Sensitivity to cold Skin lesions Risk of infections What are the fat soluble vitamins? - ADEK (Excess causes toxicity)
What is a mechanical diet? - Meals that are prepared for easy swallowing (Avoid nuts, dried, salty foods) What type of candy can you offer a patient who has reduced salivary flow? - Sour candy Foods low in potassium? - Applesauce Grapes Blueberries Raspberries Most Green veggies Can you give a patient hard candy to relieve thirst? - Yes How can you determine the patients BMI? - Divide the weight (kilo) by the height (meters squared) What is Enteral nutrition? - Feeding through the GI tract What is Parenteral nutrition (PN)? - Feeding through a vein (Last resort) Where should the PN line be placed when short term nutrition is needed (4 weeks or less)? - Subclavian or jugular vein Where should the PN line be placed when "long" term nutrition is needed (longer than 4 weeks)? - PICC is used How often should you monitor the VS of a patient receiving lipid solutions? - Every 10 mins (Monitor for reactions the 1st 30 mins) Can lipid solutions be given to patients with egg allergies? - No What can happen if you abruptly stop PN solutions? - Hypoglycemia (Decrease slowly) What type of foods should a diverticulitis patient avoid? - High-fiber foods What food does the lacto-vegetarian NOT eat? - Eggs (Lacto Ovo vegetarians eat eggs) Which patients should be on a low-purine diet? - Gout Kidney stones What are a few high purine foods? - Anchovies Herring Scallops
Mackerel Wild game Sweetbreads What are a few foods high in riboflavin? - Milk Lean meats Fish Grains Can you write on the outside of IV bags? - No (Use a label instead) Why are the veins in the forearm mist commonly used for IV sites? - They provide natural support and splint Why is a patient with heart failure not given saline solutions? - Increases fluid overload and exacerbates heart failure Why is a patient with kidney disease/failure not supposed to receive lactated ringers? Contains a potassium solution How are Central venous catheters position determined? - Xray What position should the patient be in for central line insertion, removal and tubing change? - Trendelenburg Washed red blood cells may be ordered for what 2 types of issues? - 1) Recent allergic reaction to transfusion 2) Recent stem cell transplant How are platelets administered? - Rapidly over 15-30 mins What is the Universal RBC donor? - O negative Who is the Universal recipient? - AB positive If the patient has a reaction to blood, where should the blood bag be returned to? - Blood bank Hold off on giving the patient blood if the temp exceeds? - 100 F How long should the nurse remain with the patient who has just received a blood transfusion? - 15 mins
How often should you check on a patient who is receiving fluid replacement therapy? Every hour What is the limit of time a caregiver should be exposed to radiation per shift? - 30 mins MAX What should you do with a dislodged radiation implant? - Don't touch it Can needles be recapped? - No, but if you have to, use a mechanical device to recap Can safety devices/restraints be prescribed by a nurse? - No, only a HCP can prescribe Can a prescription for a restraint be used PRN? - No Who should you call first prior to attempting an intervention of a poison ingestion? - Poison control Which population should have poison control # by each phone? - homes with children Who is most at risk of contracting Clostridium difficile (C-Diff)? - Patients in hospitals who have been on multiple long term antibiotics What are the parts of bleach/water solution to use for disinfection? - 1:10 How is Anthrax contracted? - Direct (GI, skin, inhalation) How is Smallpox contracted? - Air droplets, highly contagious How often should you check the circulation of a patient with restraints? - Every 30 mins (loosen every 2 hours) Gram measures? - Mass (Gram-mass) How are "Drops" abbreviated? - gtt What is the first step in the calculation of dosages? - Conversion What type of dropper should you use for children? - Calibrated dropper How should you administer Regular and NPH insulin? - Mix both in the same syringe (Regular than NPH) Can the nurse speed up an IV infusion rate if the schedule is running late? - No How many of the 30 compressions should you let completely recoil during CPR? - 23 of the 30
For CPR purposes, a child is defined as what age range? - 1 through 8 What are the 3 post operative stages? - Immediate 1-4 hours Intermediate 4-24 hours Extended 1-4 days How often should you turn a post-operative client that cant get from bed? - every 1-2 hours What is the most common post operative complication? - Atelectasis, the collapse of the alveoli (occurs 1-2 days after surgery) What is wound evisceration, and when does it normally happen? - The protrusion of internal organs through an incision (occurs 6-8 days after surgery) How long prior to surgery should a client discontinue aspirin use? - 48 hours What is the normal urine output of a post operative patient? - 30ml every 2 hours Fowlers & Semi fowlers is what position? - semi sitting with head raised What is the Trendelenburg position? - Lower body raised (reserve is upper body raised) What position should a patient be that had a mastectomy? - Semi-fowlers with affected side arm raised to heart level For vaginal or anal exams, what should the position be? - Lithotomy What should you do when a patient who is tube feeding needs to be turned? - Turn off feeding until completed What is the most common position for a cardiac or respiratory patient? - Head of the bed raised What is Autonomic Dysreflexia, and which position should the patient be placed in? Caused when a painful stimulus occurs below the level of spinal cord injury. (High Fowlers position) What position should the patient with a Head Injury NOT be placed in? - Flat of Trendelenburg During Cardiac catheterization what position should the patient be in? - Head elevated NO MORE than 30 degrees After cataract surgery, instruct the patient to sleep in which position? - on back or nonoperative side
What position should you place a patient who has just had a liver biopsy? - Right side laying with a rolled towel under puncture site What position should the patient be for Nasogastric tube? - HIGH Fowlers position What is the best way to turn a patient who has had spinal surgery? - logrolling What should be kept at the bedside of a patient with an endotracheal or tracheotomy tube? - BVM/Ambu bag What should you do if a chest tube is accidentally pulled from the site? - Pinch the skin together, apply a sterile dressing and put overlapping 2" tape over the dressing (call the HCP) What are the normal/average pH levels of the stomach? - 1.5 to 3.5 What should you instruct the patient to do when you remove a Nasogastric tube? - Take a deep breathe and hold What should you have at the bedside of a patient who has a Sengstaken-Blakemore tube inserted for esophageal varices - A pair of scissors When inserting a catheter into a male Urethra, you see the flow of urine, what should you do next? - Insert another 2.5 to 5 cm and inflate the ballon How often should you empty a chest tube drainage chamber? - Never, due to the risk of collapsing a lung What should you instruct the patient to do while you move a chest tube? - Valsalva maneuver What position should the patient be for an insertion of a nasogastric tube for continuous feeding? - Head at at least 45 degree When residual formula is noted in a scheduled feeding, at which point would you hold the feeding? - any residual more than 100ml (test residual for pH balance, should be 3.5 or less) How fast should intermittent feedings last? - administer over 30-60 mins What are the 3 systems of personality? - ID, Ego and SuperEgo (The have different operating principles, but in a mature/well adjusted personality, they work together under the command of the EGO) When does the SuperEgo emerge? - Phallic Stage (3-6 years old)
What is the drug Questran used for? - Lower cholesterol What does a Pericardial friction rub sound like? - Loud booming/muffled heartbeat A patient with hyperparathyroidism is likely to have elevated calcium levels, which foods should they avoid? - dairy products such as milk, cheese, ice cream, or yogurt. A client with a Sengstaken-Blakemore tube in place to treat esophageal varices suddenly becomes restless, the heart rate and blood pressure increase, what is the immediate nursing action? - cut the tube and pull it out The older patient is at risk for falls due to what? - Changes in the Neurological and Muscleskeletal systems What is a common adverse reaction to medication in the older patient? - Change in mental health status