NSG 4800 NCLEX EXAM – Accurate Solutions For
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Terms in this set (90)
The nurse is caring for a client with Answers: 2 and 4
diabetic ketoacidosis and documents
that the client is experiencing Kussmaul's
respirations. Which patterns did the Rationale: Kussmaul's respirations are abnormally deep
nurse observe? Select all that apply. and increased in rate. These occur as a result of the
1. Respirations that are shallow compensatory action by the lungs. In bradypnea,
2. Respirations that are increased rate respirations are regular but abnormally slow. Apnea is
3. Respirations that are abnormally slow described as respirations that cease for several seconds.
4. Respirations that are abnormally deep
5. Respirations that cease for several
seconds
A client who had a major stroke is Answer: 3 Clopidogrel is an antiplatelet.
prescribed aspirin, 81 mg, and
Clopidogrel. The nurse realizes that the An intravenous anticoagulant would be heparin.
drug classification of Clopidogrel is Clop - change to CLOT helps me not have a clot
1. anticoagulant.
2. intravenous anticoagulant.
3. antiplatelet.
4. thrombolytic.
,The nurse is preparing to change the Answer: D.
parenteral nutrition (PN) solution bag
and tubing. The client's central venous The client should be asked to perform the Valsalva
line is located in the right subclavian maneuver during tubing changes. This helps avoid air
vein. The nurse asks the client to take embolism during tubing changes. The nurse asks the
which essential action during the tubing client to take a deep breath, hold it, and bear down. If
change? the intravenous line is on the right, the client turns his or
her head to the left. This position increases intrathoracic
A. Breathe normally. pressure. Breathing normally and exhaling slowly and
B. Turn the head to the right. evenly are inappropriate and could enhance the
C. Exhale slowly and evenly. potential for an air embolism during the tubing change.
D. Take a deep breath, hold it, and bear
down.
The clinic nurse prepares to perform a Answers: 1, 2, 4
focused assessment on a client who is Rationale: A focused assessment focuses on a limited or
complaining of symptoms of a cold, a short-term problem, such as the client's complaint.
cough, and lung congestion. Which Because the client is complaining of symptoms of a
should the nurse include for this type of cold, a cough, and lung congestion, the nurse would
assessment? Select all that apply. focus on the respiratory system and the presence of an
1. Auscultating lung sounds infection. A complete assessment includes a complete
2. Obtaining client's temperature health history and physical examination and forms a
3. Assessing the strength of peripheral baseline database. Assessing the strength of peripheral
pulses pulses relates to a vascular assessment, which is not
4. Obtaining information about the related to this client's complaints. A musculoskeletal and
client's respirations neurological examination also is not related to this
5. Performing a musculoskeletal and client's complaints. However, strength of peripheral
neurological examination pulses and a musculoskeletal and neurological
6. Asking the client about a family history examination would be included in a complete
of any illness or disease assessment. Likewise, asking the client about a family
history of any illness or disease would be included in a
complete assessment.
,Scope of Practice So, think BASIC nursing care for an LPN. They may
What RNs can do that LPNs cannot. perform assessments, but NOT initial assessments or
Perform initial assessments or status STATUS CHANGE assessments!
change assessments. What can techs/UAP do?
Develop Care Plans • Bathe patients
Educate or teach patients and other • Walk patients (only AFTER an RN has assessed the
nurses, staff, etc about new issues. patient and said the patient can get up)
What can LPNs do? • Empty foley bags, ostomy bags (1/3 full), place patient
• Monitor patients on bedpan, and report the output to the nurse
• Taking patient vital signs and histories • Change linens
• Performing routine assessments, such To get these questions correct, ask yourself is initial
as checking blood pressure assessment involved? Is teaching involved? Is there a
• Changing bandages status change? If you need an RN to do something, DO
• Inserting IVs or catheters NOT DELEGATE IT!
• Listening to patients' concerns and
reporting back to RNs and doctors
• Ensuring patients are comfortable
• Helping patients bathe or dress
Endoscopic retrograde Answer: 1, 2, 4, 5
cholangiopancreatography (ERCP) is Rationale: ERCP is a radiographic examination of the
used to identify the location of liver, gallbladder, bile ducts, and pancreas to treat
obstruction in which organs? Select all problems of the bile and pancreatic ducts. Typically, an
that apply. MRCP is ordered first and if there is some obstruction--
1. Liver. an MRCP is diagnostic--then the doctor will then
2. Gallbladder. proceed to the ERCP which is invasive. Typically, ERCPs
3. Ilieum. are done when a patient has severe gallstone
4. Bile ducts. pancreatitis with biliary obstruction.
5. Pancreas. Which labs go up in pancreatitis?
Amylase and lipase (lipase being more specific).
LFTs will go up with gallstone related problems.
Alk phos goes up with biliary obstruction.
, The charge nurse is planning the Answers: 1 and 5
assignment for the day. Which factors Rationale: There are guidelines that the nurse should use
should the nurse remain mindful of when when delegating and planning assignments. These
planning the assignment? Select all that include the following: ensure client safety; be aware of
apply individual variations in work abilities; determine which
tasks can be delegated and to whom; match the task to
1. The acuity level of the patients the delegatee on the basis of the nurse practice act and
2. Specific request from the staff appropriate position descriptions; provide directions
3. The clustering of rooms on the unit that are clear, concise, accurate, and complete; validate
4. The number of anticipated client the delegatee's understanding of the directions;
discharges communicate a feeling of confidence to the delegatee
5. Client needs and workers abilities and and provide feedback promptly after the task is
needs performed; and maintain continuity of care as much as
possible when assigning client care. Staff requests,
convenience as in clustering client rooms, and
anticipated changes in unit census are not specific
guidelines to use when delegating and planning
assignments.
A client has been on total parenteral Answer: 4
nutrition (TPN) for 8 weeks at home. The
health care provider prescribes that the Clients receiving TPN are receiving high concentrations
TPN be weaned by 50 mL per hour per of glucose. To give the pancreas time to adjust to
day until discontinued. The client asks decreasing glucose loads, the infusion rate is tapered
the nurse why the TPN cannot just be downward. Before discontinuation of TPN, the body
stopped. The nurse explains that unless must adjust to the lowered glucose levels. If the TPN is
the TPN infusions are tapered gradually, suddenly withdrawn, the client could experience
the client is at risk for developing which rebound hypoglycemia. Options 1, 2, and 3 are not
complication? (Scroll for Answer) associated with the discontinuation of the TPN.
1. Dehydration
2. Hypokalemia
3. Hypernatremia
4. Hypoglycemia
Every Question
Add to calendar
Play your way to mastery with fun games
Match Blocks Charms NEW
Terms in this set (90)
The nurse is caring for a client with Answers: 2 and 4
diabetic ketoacidosis and documents
that the client is experiencing Kussmaul's
respirations. Which patterns did the Rationale: Kussmaul's respirations are abnormally deep
nurse observe? Select all that apply. and increased in rate. These occur as a result of the
1. Respirations that are shallow compensatory action by the lungs. In bradypnea,
2. Respirations that are increased rate respirations are regular but abnormally slow. Apnea is
3. Respirations that are abnormally slow described as respirations that cease for several seconds.
4. Respirations that are abnormally deep
5. Respirations that cease for several
seconds
A client who had a major stroke is Answer: 3 Clopidogrel is an antiplatelet.
prescribed aspirin, 81 mg, and
Clopidogrel. The nurse realizes that the An intravenous anticoagulant would be heparin.
drug classification of Clopidogrel is Clop - change to CLOT helps me not have a clot
1. anticoagulant.
2. intravenous anticoagulant.
3. antiplatelet.
4. thrombolytic.
,The nurse is preparing to change the Answer: D.
parenteral nutrition (PN) solution bag
and tubing. The client's central venous The client should be asked to perform the Valsalva
line is located in the right subclavian maneuver during tubing changes. This helps avoid air
vein. The nurse asks the client to take embolism during tubing changes. The nurse asks the
which essential action during the tubing client to take a deep breath, hold it, and bear down. If
change? the intravenous line is on the right, the client turns his or
her head to the left. This position increases intrathoracic
A. Breathe normally. pressure. Breathing normally and exhaling slowly and
B. Turn the head to the right. evenly are inappropriate and could enhance the
C. Exhale slowly and evenly. potential for an air embolism during the tubing change.
D. Take a deep breath, hold it, and bear
down.
The clinic nurse prepares to perform a Answers: 1, 2, 4
focused assessment on a client who is Rationale: A focused assessment focuses on a limited or
complaining of symptoms of a cold, a short-term problem, such as the client's complaint.
cough, and lung congestion. Which Because the client is complaining of symptoms of a
should the nurse include for this type of cold, a cough, and lung congestion, the nurse would
assessment? Select all that apply. focus on the respiratory system and the presence of an
1. Auscultating lung sounds infection. A complete assessment includes a complete
2. Obtaining client's temperature health history and physical examination and forms a
3. Assessing the strength of peripheral baseline database. Assessing the strength of peripheral
pulses pulses relates to a vascular assessment, which is not
4. Obtaining information about the related to this client's complaints. A musculoskeletal and
client's respirations neurological examination also is not related to this
5. Performing a musculoskeletal and client's complaints. However, strength of peripheral
neurological examination pulses and a musculoskeletal and neurological
6. Asking the client about a family history examination would be included in a complete
of any illness or disease assessment. Likewise, asking the client about a family
history of any illness or disease would be included in a
complete assessment.
,Scope of Practice So, think BASIC nursing care for an LPN. They may
What RNs can do that LPNs cannot. perform assessments, but NOT initial assessments or
Perform initial assessments or status STATUS CHANGE assessments!
change assessments. What can techs/UAP do?
Develop Care Plans • Bathe patients
Educate or teach patients and other • Walk patients (only AFTER an RN has assessed the
nurses, staff, etc about new issues. patient and said the patient can get up)
What can LPNs do? • Empty foley bags, ostomy bags (1/3 full), place patient
• Monitor patients on bedpan, and report the output to the nurse
• Taking patient vital signs and histories • Change linens
• Performing routine assessments, such To get these questions correct, ask yourself is initial
as checking blood pressure assessment involved? Is teaching involved? Is there a
• Changing bandages status change? If you need an RN to do something, DO
• Inserting IVs or catheters NOT DELEGATE IT!
• Listening to patients' concerns and
reporting back to RNs and doctors
• Ensuring patients are comfortable
• Helping patients bathe or dress
Endoscopic retrograde Answer: 1, 2, 4, 5
cholangiopancreatography (ERCP) is Rationale: ERCP is a radiographic examination of the
used to identify the location of liver, gallbladder, bile ducts, and pancreas to treat
obstruction in which organs? Select all problems of the bile and pancreatic ducts. Typically, an
that apply. MRCP is ordered first and if there is some obstruction--
1. Liver. an MRCP is diagnostic--then the doctor will then
2. Gallbladder. proceed to the ERCP which is invasive. Typically, ERCPs
3. Ilieum. are done when a patient has severe gallstone
4. Bile ducts. pancreatitis with biliary obstruction.
5. Pancreas. Which labs go up in pancreatitis?
Amylase and lipase (lipase being more specific).
LFTs will go up with gallstone related problems.
Alk phos goes up with biliary obstruction.
, The charge nurse is planning the Answers: 1 and 5
assignment for the day. Which factors Rationale: There are guidelines that the nurse should use
should the nurse remain mindful of when when delegating and planning assignments. These
planning the assignment? Select all that include the following: ensure client safety; be aware of
apply individual variations in work abilities; determine which
tasks can be delegated and to whom; match the task to
1. The acuity level of the patients the delegatee on the basis of the nurse practice act and
2. Specific request from the staff appropriate position descriptions; provide directions
3. The clustering of rooms on the unit that are clear, concise, accurate, and complete; validate
4. The number of anticipated client the delegatee's understanding of the directions;
discharges communicate a feeling of confidence to the delegatee
5. Client needs and workers abilities and and provide feedback promptly after the task is
needs performed; and maintain continuity of care as much as
possible when assigning client care. Staff requests,
convenience as in clustering client rooms, and
anticipated changes in unit census are not specific
guidelines to use when delegating and planning
assignments.
A client has been on total parenteral Answer: 4
nutrition (TPN) for 8 weeks at home. The
health care provider prescribes that the Clients receiving TPN are receiving high concentrations
TPN be weaned by 50 mL per hour per of glucose. To give the pancreas time to adjust to
day until discontinued. The client asks decreasing glucose loads, the infusion rate is tapered
the nurse why the TPN cannot just be downward. Before discontinuation of TPN, the body
stopped. The nurse explains that unless must adjust to the lowered glucose levels. If the TPN is
the TPN infusions are tapered gradually, suddenly withdrawn, the client could experience
the client is at risk for developing which rebound hypoglycemia. Options 1, 2, and 3 are not
complication? (Scroll for Answer) associated with the discontinuation of the TPN.
1. Dehydration
2. Hypokalemia
3. Hypernatremia
4. Hypoglycemia
