NCLEX-RN Review Exam Questions With Accurate Answers.
Do not delegate what you can EAT - accurate answers-Don't delegate what
you can:
E- Evaluate
A- Assess
T- Teach
*if unsure ask charge nurse
Follow up with performed task that has been delegated.
Baker Act - accurate answers-provides individuals who have a mental illness,
or who may harm or neglect themselves or others, with an emergency service
and temporary detention for psychiatric evaluation and voluntary or
involuntary short-term community inpatient treatment.
*nursing consideration*
-pt must have a 1:1 sitter at bedside
- within or post 24hr post baker act pt must be seen by psych.
Infants with MENINGITIS - accurate answers-s/s: poor or shrill cry (infants)
decrease LOC (lethargy)
no appeitie
fever
n/v
DX: LP
NSG INTV:
*Meningitis at 6 months (newborn) may have cerebral palsy
IV ABT tx after LP culture sent to lab
HOB elevated
monitor for s/s of increased ICP
Initiate seizure precaution.
PREVENTION Recommendation: pneumococcal vaccine at 2 months
ASSESSMENT - accurate answers-Always done at the beginning of the shift.
ALWAYS ASSESS YOUR PT WHEN PROVIDING ANY TYPE OF NSG CARE (ex: pt
c/o pain perform a pain assessment)
Head to Toe at the beginning of shift and systems or focused assessment at
least every hour during the shift
*questions: always think what you can do right then and there for the pt.
,Priority care in nursing - accurate answers-Assessment of patient, invasive
sites, bleeding
Provide O2 (usually 2L via NC)
Monitor VS
Elevate HOB
Check any tubes for kinks
Neurological assessment includes - accurate answers-LOC (especially in head
injury, PE/DVT, and fat embolism)
Mental Status
Emotional status
AAO x4 (person, place, time , and situation)
Assess cranial nerves
Assess sensory and motor reflex
PERRLA
Assess eye (sclera, conjunctiva, symmetry)
Pupil size (normal 3-4mm)
Monitor pain, temp, sensation, reflexes
Assess motor function and balance/coordination
*Infant or neonates: check fontanels
Respiratory Assessment - accurate answers-LOC
ABG* when indicated
Lung sounds (auscultate)
Respiration patterns or effort
Inspect chest symmetry
pulse oximetry
VS (specifically O2, RR and HR)
NSG INTV:
Check physiotherapy
TCDB Q2H
Incentive spirometer (10x/hr)
oral care
Elevate HOB
Cardiovascular assessment - accurate answers-LOC
VS (HR and BP) *apical pulse
Assess pulses ( grading of pulse (+1,+2)) (regular, irregular)
,Heart sounds
Cap refill
Assess CMS
GI assessment - accurate answers-Observe abdomen shape and contour (flat,
round, distended)
Palpate for pain or tenderness
Percussion
Auscultate: Bowel sounds
*Assess girth measurement if indicated.
Assess last BM
Renal Assessment - accurate answers-Urinary patterns (frequency, urgency)
Monitor VS (BP AND WEIGHT)
Assess hydration (skin turgor)
Renal labs (BUN, creatinine, specific gravity, urea, albumin, UA C&S)
Urinary output (assess for foley)
Monitor I&O
Daily weights *usually for renal failure and HF
Skin assessment - accurate answers-Assess for color, moisture, temperature,
texture, turgor, vascularity, edema, lesions, rash
Assess hair and scalp
Assess for bruising, wounds, and pressures
Assess mucosas and oral cavity (pink, most, lesions)
Assess extremities
Assess bony parts for breakdown r/t high risk areas of pressure ulcer
formation
MS assessment - accurate answers-ROM
Assess Gait
Assess posture
Muscle strength symmetry (right and left extremities)
Assess CMS
Assess skin condition (for injuries)
Assess pulses
Assess functions (ADL)
Assess for pain based on location
, Addisons: Down, Down, Down, Up, Down
Cushings: Up, Up, Up, Down, Up - accurate answers-*Addisons*:
Hyponatremia, Hypotension, Decreased blood volume, *Hyperkalemia*,
Hypoglycemia
*Cushings*: Hypernatremia, Hypertension, Increased Blood Volume,
*Hypokalemia*, Hyperglycemia
DX test in neurological - accurate answers-CT brain scan
MRI
PET scan
Cerebral angiography
Myelography
EEG
EMG
LP
Nerve conduction test
Grapefruit juice effect - accurate answers-can inhibit the metabolism of
certain drugs, thereby raising their blood levels
AVOID!!!!
EEG - accurate answers-Used to detect seizure disorders
-used to determine brain death (especially in pt in coma)
-may show that tumor, abscess, brain scar, blood clots, and infection present.
NO PAIN PROCEDURE
PT MUST LIE STILL
AVOID STIMULANTS 1-2 days prior ex:
-coffee
-chocolate
-tea
-caffine
EMG - accurate answers-Needle electrodes introduced into Skeletal Muscles to
measure changes in electrical potential of the muscles & the nerves leading to
them.
Used to detect:
1. Neuromuscular disorder
2. Determines weakness from neuropathies
Do not delegate what you can EAT - accurate answers-Don't delegate what
you can:
E- Evaluate
A- Assess
T- Teach
*if unsure ask charge nurse
Follow up with performed task that has been delegated.
Baker Act - accurate answers-provides individuals who have a mental illness,
or who may harm or neglect themselves or others, with an emergency service
and temporary detention for psychiatric evaluation and voluntary or
involuntary short-term community inpatient treatment.
*nursing consideration*
-pt must have a 1:1 sitter at bedside
- within or post 24hr post baker act pt must be seen by psych.
Infants with MENINGITIS - accurate answers-s/s: poor or shrill cry (infants)
decrease LOC (lethargy)
no appeitie
fever
n/v
DX: LP
NSG INTV:
*Meningitis at 6 months (newborn) may have cerebral palsy
IV ABT tx after LP culture sent to lab
HOB elevated
monitor for s/s of increased ICP
Initiate seizure precaution.
PREVENTION Recommendation: pneumococcal vaccine at 2 months
ASSESSMENT - accurate answers-Always done at the beginning of the shift.
ALWAYS ASSESS YOUR PT WHEN PROVIDING ANY TYPE OF NSG CARE (ex: pt
c/o pain perform a pain assessment)
Head to Toe at the beginning of shift and systems or focused assessment at
least every hour during the shift
*questions: always think what you can do right then and there for the pt.
,Priority care in nursing - accurate answers-Assessment of patient, invasive
sites, bleeding
Provide O2 (usually 2L via NC)
Monitor VS
Elevate HOB
Check any tubes for kinks
Neurological assessment includes - accurate answers-LOC (especially in head
injury, PE/DVT, and fat embolism)
Mental Status
Emotional status
AAO x4 (person, place, time , and situation)
Assess cranial nerves
Assess sensory and motor reflex
PERRLA
Assess eye (sclera, conjunctiva, symmetry)
Pupil size (normal 3-4mm)
Monitor pain, temp, sensation, reflexes
Assess motor function and balance/coordination
*Infant or neonates: check fontanels
Respiratory Assessment - accurate answers-LOC
ABG* when indicated
Lung sounds (auscultate)
Respiration patterns or effort
Inspect chest symmetry
pulse oximetry
VS (specifically O2, RR and HR)
NSG INTV:
Check physiotherapy
TCDB Q2H
Incentive spirometer (10x/hr)
oral care
Elevate HOB
Cardiovascular assessment - accurate answers-LOC
VS (HR and BP) *apical pulse
Assess pulses ( grading of pulse (+1,+2)) (regular, irregular)
,Heart sounds
Cap refill
Assess CMS
GI assessment - accurate answers-Observe abdomen shape and contour (flat,
round, distended)
Palpate for pain or tenderness
Percussion
Auscultate: Bowel sounds
*Assess girth measurement if indicated.
Assess last BM
Renal Assessment - accurate answers-Urinary patterns (frequency, urgency)
Monitor VS (BP AND WEIGHT)
Assess hydration (skin turgor)
Renal labs (BUN, creatinine, specific gravity, urea, albumin, UA C&S)
Urinary output (assess for foley)
Monitor I&O
Daily weights *usually for renal failure and HF
Skin assessment - accurate answers-Assess for color, moisture, temperature,
texture, turgor, vascularity, edema, lesions, rash
Assess hair and scalp
Assess for bruising, wounds, and pressures
Assess mucosas and oral cavity (pink, most, lesions)
Assess extremities
Assess bony parts for breakdown r/t high risk areas of pressure ulcer
formation
MS assessment - accurate answers-ROM
Assess Gait
Assess posture
Muscle strength symmetry (right and left extremities)
Assess CMS
Assess skin condition (for injuries)
Assess pulses
Assess functions (ADL)
Assess for pain based on location
, Addisons: Down, Down, Down, Up, Down
Cushings: Up, Up, Up, Down, Up - accurate answers-*Addisons*:
Hyponatremia, Hypotension, Decreased blood volume, *Hyperkalemia*,
Hypoglycemia
*Cushings*: Hypernatremia, Hypertension, Increased Blood Volume,
*Hypokalemia*, Hyperglycemia
DX test in neurological - accurate answers-CT brain scan
MRI
PET scan
Cerebral angiography
Myelography
EEG
EMG
LP
Nerve conduction test
Grapefruit juice effect - accurate answers-can inhibit the metabolism of
certain drugs, thereby raising their blood levels
AVOID!!!!
EEG - accurate answers-Used to detect seizure disorders
-used to determine brain death (especially in pt in coma)
-may show that tumor, abscess, brain scar, blood clots, and infection present.
NO PAIN PROCEDURE
PT MUST LIE STILL
AVOID STIMULANTS 1-2 days prior ex:
-coffee
-chocolate
-tea
-caffine
EMG - accurate answers-Needle electrodes introduced into Skeletal Muscles to
measure changes in electrical potential of the muscles & the nerves leading to
them.
Used to detect:
1. Neuromuscular disorder
2. Determines weakness from neuropathies
