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NCLEX/RN/NCLEX RN TEST BANK ACTUAL EXAM 2025 GUARANTEED PASS!!

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NCLEX/RN/NCLEX RN TEST BANK ACTUAL EXAM 2025 GUARANTEED PASS!! /.Is a process of learning a different culture to adapt to a new or changing environment. - Answer-Acculturation. /.It is a subjective perspective of the person's heritage and a sense of belonging to a group - Answer-Ethnic identity /.Include meditation, relaxation techniques, imagery, music therapy, massage, touch, laughter, humor, & spiritual measures (prayer). - Answer-Low-risk therapies: /.Because of their health & dietary practices, Native Americans, Latino Americans, Hispanic Americans, & African Americans. - Answer-High risk of obesity & diabetes mellitus /.Surgery is not prohibited, but the administration of blood and blood products is forbidden. This religious group believes the soul cannot live after death. Administration of medication is an acceptable practice except if the medication is derived from blood products. - Answer-Jehovah's Witnesses /.Believers adhere to dietary kosher laws. In this religion, the dairy-meat combination is unacceptable. Only fish that have scales and fins are allowed; meats that are allowed include animals that are vegetable eaters, cloven-hoofed, and ritually slaughtered. - Answer-Orthodox Judaism /.include whole medical systems, mind-body medicine, biologically based practices, manipulative & body-based practices, & energy medicine. - Answer-Five categories of complementary and alternative medicine (CAM): /.Focused, maintains strong control, makes decisions, & addresses all problems. Dominates group & commands, rather than seeks suggestions or input. Manager addresses problem (quality improvement) with taff, designs a plan without input, & wants all problems reported directly back to her - Answer-Autocratic leader /.Participative & would likely meet with each staff person individually to determine staff member's perception of problem. Would also speak with the staff about any issues & ask the staff for input with developing a plan. - Answer-Democratic leader /.Passive and nondirective. Would state what the problem was & inform staff that the staff needed to come up with a plan to "fix it." - Answer-Laissez-faire leader /.Assessment findings include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck & hand vein distention, altered LOC, & decreased hematocrit. - Answer-Overhydration or fluid overload & occurs when fluid intake or fluid retention /.Avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, & tomatoes - Answer-Common food sources of potassium: /.Muscle weakness, increased urinary output, & decreased specific gravity of the urine would be noted - Answer-Hyponatremia /.Causative factors relate to malnutrition or starvation & the use of aluminum hydroxide-based or magnesium-based antacids. Malnutrition is associated with alcoholism. - Answer-Hypophosphatemia /.Renal insufficiency, hypoparathyroidism, & tumor lysis syndrome; causative factors. Should avoid foods high in phosphates; fish, eggs, milk products, vegetables, whole grains, & carbonated beverages. - Answer-Hyperphosphatemia /.Vomiting, diarrhea, conditions that increased respiration's or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, presence of ileostomy or colostomy. Diuretics, & gastrointestinal suctioning. - Answer-Causes of a fluid volume deficit /.Decreased kidney function, heart failure, hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds & body cavities, & excessive ingestion of sodium. - Answer-Causes of overhydration or fluid overload: /.Trauma, burns, sepsis, or metabolic or respiratory acidosis. - Answer-Hyperkalemia causes: /.Cushing's syndrome or colitis & over use of laxatives. - Answer-Hypokalemia causes: /.Decreased pH & decreased HCO3. Occurs in kidney disease; diabetic ketoacidosis; high fat diet; insufficient metabolism of carbohydrates; malnutrition; ingestion of toxins, such as acetylsalicylic acid (aspirin); malnutrition; severe diarrhea. Intestinal secretion high in bicarbonate & may be lost through enteric drainage tubes, an ileostomy, or diarrhea. - Answer-Metabolic acidotic /.Nausea & vomiting. Loss of gastric acid, cause pH & HCO3 to increase. Symptoms experienced would include hypoventilation & tachycardia. - Answer-Metabolic alkalosis /.Decreased pH and an increased CO2. Hypoventalation & COPD - Answer-Respiratory acidotic /.Increased pH & decreased CO2. Hyperventalation, Lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, numbness & tingling of extremities. Hyperventilation (tachypnea) occurs. - Answer-Respiratory alkalotic /.Sample for PT & INR level to determine anticoagulation status & risk for bleeding - Answer-Warfarin (Coumadin) /.aPTT monitors the effects. Anticoagulant used most often during hemodialysis. Monitors extent of anticoagulation checking PTT, which is appropriate measure heparin effect. Protamine sulfate is antidote. - Answer-Heparin /.Dark green leafy vegetables good source iron, oranges are a good source of vitamin C, which enhances iron absorption. - Answer-Iron deficiency anemia foods in diet: /.May lack B12 in diet. - Answer-Vegans /.Include fruits & vegetables - Answer-Low sodium foods: /.Highly processed or refined foods (tomato soup, instant oatmeal), Saltwater fish & shellfish. Smoked foods, - Answer-High Sodium foods: /.Water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, ice pops, and regular or decaffeinated coffee or tea. - Answer-Clear liquid diet: /.Pulling, Vegetable juice, Pureed vegetables, plain ice cream, sherbet, breakfast drinks, milk, pudding & custard, soups that are strained, refined cooked cereals, & strained vegetable juices. - Answer-Full liquid diet: /.Pork products rich in this vitamin. Other good food sources include nuts, whole grain cereals, & legumes. - Answer-High Thiamine foods /.On the left side, with the head lower than the feet. This position used to minimize effect of air traveling as a bolus to lungs by trapping it in right side of heart. - Answer-Suspects air embolism. Should immediately place client in which position? /.Assess for known allergies to eggs to prevent anaphylaxis. - Answer-Fat emulsion (lipids) /.Signs include excessive thirst, fatigue, restlessness, confusion, weakness, Kussmaul's respirations, diuresis, & coma when severe. If has these symptoms, blood glucose level should be checked immediately. - Answer-Hyperglycemia: /.Temperature and weight: Temperature monitored to detect infection, potential complication of therapy. Infection also could result in sepsis because catheter in blood vessel. Weight monitored for effectiveness nutritional therapy & detect hypervolemia. - Answer-Parenteral nutrition; PN monitor /.Burns, exacerbation Crohn's disease, persistent nausea & vomiting due to chemotherapy. Had extensive surgery, multiple fractures, are septic, have advanced cancer or AIDS. (Electronic infusion pump used to administer) - Answer-Parenteral nutrition; Patients needing /.10% dextrose in water until new PN solution becomes available. - Answer-Parenteral nutrition; If PN bag empty hang /.IV dislodged from vein & is lying in subcutaneous tissue. Pallor, coolness, & swelling are results of IV fluid being deposited in tissue. Corrective action is remove catheter & start new IV line at another site. - Answer-Infiltrated IV /.Discomfort at site, redness, warmth, & swelling proximal to catheter. If phlebitis occurs, discontinue IV line & insert new IV line at different site. Apply warm moist compresses to area speed resolution of inflammation. Notify (HCP). Document occurrence, actions taken, & client response. - Answer-Phlebitis at IV site: /.Produces a rash, redness, & itching. - Answer-An allergic reaction at IV site: /.Characterized by ecchymosis, swelling, & leakage at IV insertion site, as well as hard & painful lumps at site. - Answer-Hematoma /.Dyspnea, a swollen tongue, & cyanosis. - Answer-Hypersensitivity reaction: /.Taught minor activity restrictions apply with this type of catheter. Protect site during bathing & should carry or wear Medic-Alert ID. Have repair kit in home for use as needed because catheter is for long-term use. - Answer-PICC line /.Before beginning administration IV solution, assess whether chest radiograph reveals central catheter is in proper place. Portable chest X-ray. - Answer-Central venous catheter insertion: /.Characterized by chills, fever, malaise, headache, nausea, vomiting, backache, & tachycardia. - Answer-Systemic infection /.Characterized by tachycardia, dyspnea, hypotension, cyanosis, decreased LOC, anxiety, feelings of impending doom, chest pain, & hypotension. Place left side in Trendelenburg's position. Lying left side may prevent air from flowing into pulmonary veins. Trendelenburg's position increases intrathoracic pressure, which decreases amount of blood pulled into vena cava during inspiration. - Answer-Air embolism /.Occurs with transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, & development of shock - Answer-Septicemia /.Necessary for proper blood clotting. Insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, & mucous membranes. - Answer-Platelets /.Order of priority is to rescue patient in immediate danger. Next activate fire alarm. Close all doors & fire extinguished. - Answer-Fire event /.Transmitted by droplet infection. Precautions include private room or cohort client & use of standard precaution mask. - Answer-Meningococcal pneumonia /.Best results sitting head of bed elevated 45 to 90 degrees. Semi-Fowler's or high Fowler's position. Mouthpiece should be covered completely & tightly while inhales slowly, with constant flow through unit. Breath should be held for 5 seconds before exhaling slowly. - Answer-Incentive spirometer /.Placed in left Sims position so enema solution can flow by gravity in natural direction of colon. - Answer-Cleansing enema /.Preconventional stage, morals are thought to be motivated by punishment & reward. - Answer-Kohlberg's theory of moral development /.Should not try anticipate newborn infant needs but allow newborn infant to signal needs. If newborn infant is not allowed to signal a need, newborn will not learn how to control environment. Delayed or prolonged response to newborn infant's signal would inhibit development trust & lead to mistrust of others - Answer-Erikson's psychosocial development theory /.Child has the ability to think abstractly and logically. - Answer-Formal operations stage of Piaget's cognitive developmental theory /.Child begins to understand the environment. - Answer-Paiget's sensorimotor stage

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NCLEX/RN/NCLEX RN TEST BANK
ACTUAL EXAM 2025 GUARANTEED
PASS!!

/.Is a process of learning a different culture to adapt to a new or changing environment.
- Answer-✅Acculturation.

/.It is a subjective perspective of the person's heritage and a sense of belonging to a
group - Answer-✅Ethnic identity

/.Include meditation, relaxation techniques, imagery, music therapy, massage, touch,
laughter, humor, & spiritual measures (prayer). - Answer-✅Low-risk therapies:

/.Because of their health & dietary practices, Native Americans, Latino Americans,
Hispanic Americans, & African Americans. - Answer-✅High risk of obesity & diabetes
mellitus

/.Surgery is not prohibited, but the administration of blood and blood products is
forbidden. This religious group believes the soul cannot live after death. Administration
of medication is an acceptable practice except if the medication is derived from blood
products. - Answer-✅Jehovah's Witnesses

/.Believers adhere to dietary kosher laws. In this religion, the dairy-meat combination is
unacceptable. Only fish that have scales and fins are allowed; meats that are allowed
include animals that are vegetable eaters, cloven-hoofed, and ritually slaughtered. -
Answer-✅Orthodox Judaism

/.include whole medical systems, mind-body medicine, biologically based practices,
manipulative & body-based practices, & energy medicine. - Answer-✅Five categories of
complementary and alternative medicine (CAM):

/.Focused, maintains strong control, makes decisions, & addresses all problems.
Dominates group & commands, rather than seeks suggestions or input. Manager
addresses problem (quality improvement) with taff, designs a plan without input, &
wants all problems reported directly back to her - Answer-✅Autocratic leader

/.Participative & would likely meet with each staff person individually to determine staff
member's perception of problem. Would also speak with the staff about any issues &
ask the staff for input with developing a plan. - Answer-✅Democratic leader

,/.Passive and nondirective. Would state what the problem was & inform staff that the
staff needed to come up with a plan to "fix it." - Answer-✅Laissez-faire leader

/.Assessment findings include cough, dyspnea, crackles, tachypnea, tachycardia,
elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck &
hand vein distention, altered LOC, & decreased hematocrit. - Answer-✅Overhydration
or fluid overload & occurs when fluid intake or fluid retention

/.Avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork,
beef, veal, raisins, spinach, strawberries, & tomatoes - Answer-✅Common food
sources of potassium:

/.Muscle weakness, increased urinary output, & decreased specific gravity of the urine
would be noted - Answer-✅Hyponatremia

/.Causative factors relate to malnutrition or starvation & the use of aluminum hydroxide-
based or magnesium-based antacids. Malnutrition is associated with alcoholism. -
Answer-✅Hypophosphatemia

/.Renal insufficiency, hypoparathyroidism, & tumor lysis syndrome; causative factors.
Should avoid foods high in phosphates; fish, eggs, milk products, vegetables, whole
grains, & carbonated beverages. - Answer-✅Hyperphosphatemia

/.Vomiting, diarrhea, conditions that increased respiration's or increased urinary output,
insufficient intravenous fluid replacement, draining fistulas, presence of ileostomy or
colostomy. Diuretics, & gastrointestinal suctioning. - Answer-✅Causes of a fluid volume
deficit

/.Decreased kidney function, heart failure, hypotonic fluids to replace isotonic fluid
losses, excessive irrigation of wounds & body cavities, & excessive ingestion of sodium.
- Answer-✅Causes of overhydration or fluid overload:

/.Trauma, burns, sepsis, or metabolic or respiratory acidosis. - Answer-✅Hyperkalemia
causes:

/.Cushing's syndrome or colitis & over use of laxatives. - Answer-✅Hypokalemia
causes:

/.Decreased pH & decreased HCO3. Occurs in kidney disease; diabetic ketoacidosis;
high fat diet; insufficient metabolism of carbohydrates; malnutrition; ingestion of toxins,
such as acetylsalicylic acid (aspirin); malnutrition; severe diarrhea. Intestinal secretion
high in bicarbonate & may be lost through enteric drainage tubes, an ileostomy, or
diarrhea. - Answer-✅Metabolic acidotic

,/.Nausea & vomiting. Loss of gastric acid, cause pH & HCO3 to increase. Symptoms
experienced would include hypoventilation & tachycardia. - Answer-✅Metabolic
alkalosis

/.Decreased pH and an increased CO2. Hypoventalation & COPD - Answer-
✅Respiratory acidotic

/.Increased pH & decreased CO2. Hyperventalation, Lethargy, lightheadedness,
confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting,
epigastric pain, numbness & tingling of extremities. Hyperventilation (tachypnea)
occurs. - Answer-✅Respiratory alkalotic

/.Sample for PT & INR level to determine anticoagulation status & risk for bleeding -
Answer-✅Warfarin (Coumadin)

/.aPTT monitors the effects. Anticoagulant used most often during hemodialysis.
Monitors extent of anticoagulation checking PTT, which is appropriate measure heparin
effect. Protamine sulfate is antidote. - Answer-✅Heparin

/.Dark green leafy vegetables good source iron, oranges are a good source of vitamin
C, which enhances iron absorption. - Answer-✅Iron deficiency anemia foods in diet:

/.May lack B12 in diet. - Answer-✅Vegans

/.Include fruits & vegetables - Answer-✅Low sodium foods:

/.Highly processed or refined foods (tomato soup, instant oatmeal), Saltwater fish &
shellfish. Smoked foods, - Answer-✅High Sodium foods:

/.Water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade, ice
pops, and regular or decaffeinated coffee or tea. - Answer-✅Clear liquid diet:

/.Pulling, Vegetable juice, Pureed vegetables, plain ice cream, sherbet, breakfast drinks,
milk, pudding & custard, soups that are strained, refined cooked cereals, & strained
vegetable juices. - Answer-✅Full liquid diet:

/.Pork products rich in this vitamin. Other good food sources include nuts, whole grain
cereals, & legumes. - Answer-✅High Thiamine foods

/.On the left side, with the head lower than the feet. This position used to minimize effect
of air traveling as a bolus to lungs by trapping it in right side of heart. - Answer-
✅Suspects air embolism. Should immediately place client in which position?

, /.Assess for known allergies to eggs to prevent anaphylaxis. - Answer-✅Fat emulsion
(lipids)

/.Signs include excessive thirst, fatigue, restlessness, confusion, weakness, Kussmaul's
respirations, diuresis, & coma when severe. If has these symptoms, blood glucose level
should be checked immediately. - Answer-✅Hyperglycemia:

/.Temperature and weight: Temperature monitored to detect infection, potential
complication of therapy. Infection also could result in sepsis because catheter in blood
vessel. Weight monitored for effectiveness nutritional therapy & detect hypervolemia. -
Answer-✅Parenteral nutrition; PN monitor

/.Burns, exacerbation Crohn's disease, persistent nausea & vomiting due to
chemotherapy. Had extensive surgery, multiple fractures, are septic, have advanced
cancer or AIDS. (Electronic infusion pump used to administer) - Answer-✅Parenteral
nutrition; Patients needing

/.10% dextrose in water until new PN solution becomes available. - Answer-
✅Parenteral nutrition; If PN bag empty hang

/.IV dislodged from vein & is lying in subcutaneous tissue. Pallor, coolness, & swelling
are results of IV fluid being deposited in tissue. Corrective action is remove catheter &
start new IV line at another site. - Answer-✅Infiltrated IV

/.Discomfort at site, redness, warmth, & swelling proximal to catheter. If phlebitis occurs,
discontinue IV line & insert new IV line at different site. Apply warm moist compresses
to area speed resolution of inflammation. Notify (HCP). Document occurrence, actions
taken, & client response. - Answer-✅Phlebitis at IV site:

/.Produces a rash, redness, & itching. - Answer-✅An allergic reaction at IV site:

/.Characterized by ecchymosis, swelling, & leakage at IV insertion site, as well as hard
& painful lumps at site. - Answer-✅Hematoma

/.Dyspnea, a swollen tongue, & cyanosis. - Answer-✅Hypersensitivity reaction:

/.Taught minor activity restrictions apply with this type of catheter. Protect site during
bathing & should carry or wear Medic-Alert ID. Have repair kit in home for use as
needed because catheter is for long-term use. - Answer-✅PICC line

/.Before beginning administration IV solution, assess whether chest radiograph reveals
central catheter is in proper place. Portable chest X-ray. - Answer-✅Central venous
catheter insertion:

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