Verified Questions and Answers – Complete NCLEX-
Style Prep
ATIAnswers
,Med C
, Rationale : Morphine can cause respiratory depression if given too much. Also you
should ALWAYS ASSESS the patient first when a med error is performed to make
sure med error doesn‟t put the client‟s health in risk.
4. Anurseis preparingto administerdiphenhydramine 20 mgorallyto a6-year-old child who has
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difficulty swallowing pills. Available is diphenhydramine 12.5 mg/5 mL oral syrup. Which of the
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following images shows the correct # of mL the nurse should administer? (Round the answer to the
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nearest whole number.)
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Clickonthesyringethat has8 mLofmed. t t t t t t t t t
20mgx(5mL/12.5mg)=8 mL t t t t t t
5. A nurse is caring fora 6-year-old child who has a newprescription forcefoxitin80 mg/kg/day
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administered intravenouslyevery6 hour. The child weighs 20 kg. How much
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cefoxitinshouldthenurseadministerwitheachdose?(Roundtheanswertothenearestwhole
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number. Use a leading zero if it applies. Do not use a trailing zero.)
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Soitsayseachdose forthe finalanswer,but weare given80 mg/kg/day.
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80x20=1600 /4 (dose is givenevery6 hours aday)=400 mg
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Rationale:80 mgx 20kg=1,600 1,600/4 xday(q6h)= 400 mg
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6. Anurse ispreparingtoadminister IV fluidstoaclient. The nurse notessparks whenplugging in the
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t IVpump. Whichofthe followingactions should the nurse take first?
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a. Labelthepump withadefectiveequipmentsticker. t t t t t t t
b. Unplugthe pump. t t
c. Obtainareplacementpump. t t t
d. Notifiedthebiomedicaldepartmentto fixthepump. t t t t t t t
Rationale:Prioritizationquestion.YOUWILLFIRSTUNPLUGtheIVpumptoavoid t t t t t t t t t t t
causing a fire.
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7. Anurse iscaring foraclient who hasasurgical wound.Whichofthe followinglaboratory values
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places the client at risk for poor wound healing?
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a. Serumalbumin 3 g/dL t t t
Med C
, b. Totallymphocytecount2400 mm3 t t t t
c. HCT42% t
d. HGB16g/dL t
Rationale:Albumin in low.Normalrange is3.5to5.5 g/dL. Lowalbuminplaces the client t t t t t t t t t t t t t t t
at risk forpoor wound healing. The other lab values are within normal limits.
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8. Anurseispreparingtocheckaclient'sbloodpressure.Whichofthefollowingactionsshould the
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nurse take? Chapter27 Vitals signs page 244
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a. Applythecuffabovetheclient‟santecubitalfossa. t t t t t t t
b. Usea cuffwith a width thatis about 60% ofthe client's arm circumference. -width ofthe
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cuffshould be 40 % of arm circumference
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c. Howtheclients sitwithhisarmrestingabove the levelofhis heart. - MUST BE AT HEART
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t LEVEL
d. Releasethepressureontheclient's arm 5to 6 mmpersecond. -pressurereleaseshould not be
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more than2 to 3 mm hgper second
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Rationale: ATI FUNDA says 40% of the arm circumference pg. 139. Release the pressureno t t t t t t t t t t t t t t
fasterthan2 to 3 mm Hgper second. Applythe BP cuff 2.5 cm (1 in) above the antecubital space
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with the brachial arteryin line with the marking on the cuff.Apply theBP cuff2.5 cm(1 in)
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abovetheantecubitalspacewiththebrachialartery in line with the marking on the cuff.
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9. Anurseispreparingtoperformnasal tracheal suctioningforaclient. Which ofthefollowing is
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anappropriate action forthe nurse to take? Chapter53 Airway management page 563
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a. Holdthesuctioncatheter withthecleannon-dominant hand.
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b. Applysuctioningfor20 to30seconds.- 10-15seconds is the maximum. t t t t t t t t t t t t
c. Placethecatheter ina locationthat iscleananddryfor later use new line.- NEVER EVER
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REUSE THESUCTION CATHETER. youthrow it awayafter being used.
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d. Usesurgical asepsiswhen performing theprocedure.-book say medical asepsis
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t which is maybe the same thing . t t t t t t
Rationale:steriletechnique fortrachea t t t t
Med C