NCLEX PREP ARCHER — COMPREHENSIVE REVIEW STUDY GUIDE
Complete Question & Answer Set | Study Reference: quizlet.com/_9wlgpr
1. List in order how the PPE should be put on: 9. A 50-yr-old pt has been under extreme job stress for 10 yrs
1st-Gown | 2nd-Mask/Respirator | 3rd-Goggles | 4th-Gloves and is diagnosed as having an enlarged heart. The nurse
understands which factor in his history is a modifiable risk
2. List in order how the PPE should be removed: factor for heart disease?
1st-Gloves | 2nd-Goggles | 3rd-Gown | 4th-Mask/Respirator a. He eats beef once a week
b. He exercises four times a week
3. The nurse teaches the family of a patient with end stage c. He has a family history of heart attacks
renal disease to offer foods high in? d. He smokes one pack of cigarettes a day
a. Fluids
Answer: d. He smokes one pack of cigarettes a day
b. Protein
c. Potassium
10. Liver involvement is associated with Reye's syndrome.
d. Carbohydrates When caring for children with this condition, the nurse takes
Answer: d. Carbohydrates with special precaution?
a. Turning and positioning
4. A pt has an epidural for the birth of her child. While b. Assessing the level of consciousness
massaging the fundus, it is found to be firm and located under c. Administering intramuscular injections
the right rib cage. To alleviate this problem, the nurse should d. Monitoring output from the urinary catheter
first:
Answer: c. Administering intramuscular injections
a. Empty the pt's bladder
b. Initiate breast feeding the infant
11. The nurse anticipates which type of isolation precautions
c. Give Oxytocic drugs as ordered
should be taken with a 4-month old infant with diarrhea?
d. Massage the uterus for another 15 minutes
a. Strict precautions
Answer: a. Empty the pt's bladder b. Droplet precautions
c. Contact precautions
5. The nurse is caring for a newborn who is pale and jittery d. Airborne precautions
and has a high-pitched cry. The Primary nursing action is to:
Answer: c. Contact precautions
a. Check the newborn's serum glucose level
b. Obtain the newborn's axillary temp
12. An infant is brought to the ER by EMS with suspected
c. Review the maternal history for substance abuse
SIDS. The infants' parents have accompanied EMS and are
d. Determine if the mother was anxious during the birthing present when the infant is pronounced dead. The most
process important aspect of compassionate care for the parent is to:
Answer: a. Check the newborn's serum glucose level a. Explain that the death is not their fault
b. Allow the parents to say goodbye to the baby
6. A pt w/heart failure is receiving digoxin and furosemide. The c. Gather data about the events prior to the death
lab values of the pt include serum digoxin 2.9ng/mL and K+ d. Encourage the parents to join a support group
3.2mEq/L. Based on these lab results the most appropriate
nursing action is to: Answer: b. Allow the parents to say goodbye to the baby
a. Withhold the next dose of Furosemide
13. A nurse has reinforced teaching w/a client's spouse about
b. Administer an addt'l dose of digoxin
how to change the client's colostomy bag. The nurse Best
c. Notify the physician of the lab results
determines that the spouse understands the procedure by:
d. These results are w/in normal limits and require no action
a. Asking if the spouse has any questions
Answer: c. Notify the physician of the lab results b. Asking if the spouse understands what items are needed to
perform the procedure
7. A 64-year-old man is admitted to the ER w/complaints of c. Having the spouse perform the procedure and observing as
shortness of breath, heartburn, and pain in the left shoulder. the procedure is performed
After obtaining vital signs, the nurse performs a focused d. Asking if the spouse feels comfortable performing the
assessment related to the pt's: procedure
a. Heart
Answer: c. Having the spouse perform the procedure and
b. Abdomen
observing as the procedure is performed
c. Current stressors
d. Recent life changes 14. A male patient who had a pacemaker inserted relates to the
Answer: a. Heart nurse that he is apprehensive about being discharged
because he does not fully understand the pacemaker and what
8. One nursing intervention in the plan of care for a pt w/ to expect when he gets home. The most therapeutic response
paranoid personality disorder is promoting consensual by the nurse is:
validation of reality. Which nursing action is most appropriate a. "All people who have a pacemaker are concerned at first."
to implement this plan? b. "Tell me what you don't understand about your pacemaker."
a. Reinforcing the facts of the situation c. "Don't worry; I will teach you everything you need to know."
b. Encouraging verbalization of feelings d. "I will provide you with written instructions before you leave."
c. Administering antidepressant medications Answer: b. "Tell me what you don't understand about your
d. Using humor to challenge patient misperceptions pacemaker."
Answer: a. Reinforcing the facts of the situation
Page 1 of 6
, 15. A 10-year-old girl with type one diabetes receives her 27. When is the age range of Erickson's developmental stages
dinner tray. The child states that she hates broccoli and of Ego Integrity vs Despair: Answer: 65 yrs old - Death
instead wants corn on the cob. The most therapeutic response
by the nurse is: 28. What causes respiratory acidosis?
a. "Yes, but only half and Ear is allowed."
Answer: Respiratory problems; acute respiratory acidosis by
b. "No vegetable exchanges are permitted."
hypoventilation from drugs or neurological problems that
c. "Corn is considered a bread exchange." depress breathing
d. "One vegetable can be exchanged for any other vegetable."
Answer: c. "Corn is considered a bread exchange." 29. What are some signs and symptoms of respiratory
acidosis?
16. A women's labor is being augmented with Pitocin IV. Answer: Confusion, lethargy to stupor and, if not treated:
Contractions have been 2 to 3 minutes apart, lasting 60 shortness of breath, fatigue, sleepiness
seconds, and moderately firm. When palpating a patient's
abdomen, the nurse identify as a firm contraction lasting 2 1/2 30. What are the causes for respiratory alkalosis?
minutes. The nurse:
Answer: Hyperventilation resulting from prolonged
a. Turns off the Pitocin IV mechanical ventilation, high altitudes, and excessive fear
b. Increases the Pitocin IV and anxiety during pulmonary exam
c. Encourages the patient to void
d. Encourages deep breathing exercises 31. What are the signs and symptoms of respiratory alkalosis?
Answer: a. Turns off the Pitocin IV Answer: Serum pH increases; lightheadedness, dizziness,
numbness of the hands and feet, heart rate increases,
17. A patient in the cardiac unit of the hospital is diagnosed pulses weak and thready
with heart failure. The patient complains about the food, the
room temperature, and the noise on during hours of sleep. 32. What causes metabolic alkalosis?
These behaviors should cause the nurse to consider what Answer: Overuse or abusive antacids or baking soda,
factor? prolonged vomiting, or NG suctioning
a. Hypokalemia
b. Digitalis toxicity 33. What are some signs and symptoms of metabolic
c. Decreased cardiac output alkalosis?
d. Anxiety related to heart failure Answer: Related to hypokalemia which can involve
Answer: d. Anxiety related to heart failure weakness, dysrhythmias, and hypocalcemia which is related
to headache, lethargy, neuromuscular excitability
18. When a patient is receiving chemotherapy, it is important
for the nurse to assess the patient in order to implement 34. What causes metabolic acidosis?
appropriate interventions. The nurse assesses the patient for: Answer: Too much acid in the body or by too little
a. Hair loss bicarbonate. Uncontrolled diabetes, end stage renal failure,
b. Oral lesions severe diarrhea, or prolonged NG suctioning
c. Side effects of chemotherapy
d. Neutropenia 35. What are some of the signs and symptoms of metabolic
acidosis?
Answer: c. Side effects of chemotherapy
Answer: Serum pH decreases as the bicarb level decreases;
19. List in order Maslow's hierarchy of needs: confusion, lethargy, Kussmaul respirations
1st-basic physiological needs | 2nd-Safety and security | 3rd-Love
36. What is this an example of? Low pH, high or normal HCO3,
and belonging | 4th-Self-esteem | 5th-Self actualization
pCO2 high Answer: Respiratory Acidosis
20. What is the age range of Erickson's developmental stages
of Trust vs Mistrust: Answer: Birth-18 months 37. What is this an example of? High pH, low or normal HCO3,
pCO2 low Answer: Respiratory Alkalosis
21. What is the age range of Erickson's developmental stage in
Autonomy vs Shame & Doubt: Answer: 18 months-3 yrs old 38. What is this an example of? Low pH, Low HCO3, Low or
normal pCO2 Answer: Metabolic Acidosis
22. What is the age range of Erickson's developmental stages
of Initiative vs Guilt: Answer: 3-6 yrs old 39. What is this an example of? High pH, High HCO3, High or
normal pCO2 Answer: Metabolic Alkalosis
23. What is the age range of Erickson's developmental stages
of Industry vs Inferiority: Answer: 6-12 yrs old 40. An otherwise healthy individual has experienced severe
diarrhea for 36 hours. The nurse specifically will note
24. What is the age range of Erickson's developmental stages indications that the patient is experiencing:
a. Malnutrition
and Identity vs Role Confusion: Answer: 12-20 yrs old
b. Malabsorption
25. What is the age range of Erickson's developmental stages c. Metabolic alkalosis
d. Metabolic acidosis
in Intimacy vs Isolation: Answer: 20-30 yrs old
Answer: d. Metabolic acidosis
26. What is the age range of Erickson's developmental stages
of Generativity vs Stagnation: Answer: 30-65 yrs old 41. What is the normal range for pH level? Answer: 7.35-7.45
Page 2 of 6
Complete Question & Answer Set | Study Reference: quizlet.com/_9wlgpr
1. List in order how the PPE should be put on: 9. A 50-yr-old pt has been under extreme job stress for 10 yrs
1st-Gown | 2nd-Mask/Respirator | 3rd-Goggles | 4th-Gloves and is diagnosed as having an enlarged heart. The nurse
understands which factor in his history is a modifiable risk
2. List in order how the PPE should be removed: factor for heart disease?
1st-Gloves | 2nd-Goggles | 3rd-Gown | 4th-Mask/Respirator a. He eats beef once a week
b. He exercises four times a week
3. The nurse teaches the family of a patient with end stage c. He has a family history of heart attacks
renal disease to offer foods high in? d. He smokes one pack of cigarettes a day
a. Fluids
Answer: d. He smokes one pack of cigarettes a day
b. Protein
c. Potassium
10. Liver involvement is associated with Reye's syndrome.
d. Carbohydrates When caring for children with this condition, the nurse takes
Answer: d. Carbohydrates with special precaution?
a. Turning and positioning
4. A pt has an epidural for the birth of her child. While b. Assessing the level of consciousness
massaging the fundus, it is found to be firm and located under c. Administering intramuscular injections
the right rib cage. To alleviate this problem, the nurse should d. Monitoring output from the urinary catheter
first:
Answer: c. Administering intramuscular injections
a. Empty the pt's bladder
b. Initiate breast feeding the infant
11. The nurse anticipates which type of isolation precautions
c. Give Oxytocic drugs as ordered
should be taken with a 4-month old infant with diarrhea?
d. Massage the uterus for another 15 minutes
a. Strict precautions
Answer: a. Empty the pt's bladder b. Droplet precautions
c. Contact precautions
5. The nurse is caring for a newborn who is pale and jittery d. Airborne precautions
and has a high-pitched cry. The Primary nursing action is to:
Answer: c. Contact precautions
a. Check the newborn's serum glucose level
b. Obtain the newborn's axillary temp
12. An infant is brought to the ER by EMS with suspected
c. Review the maternal history for substance abuse
SIDS. The infants' parents have accompanied EMS and are
d. Determine if the mother was anxious during the birthing present when the infant is pronounced dead. The most
process important aspect of compassionate care for the parent is to:
Answer: a. Check the newborn's serum glucose level a. Explain that the death is not their fault
b. Allow the parents to say goodbye to the baby
6. A pt w/heart failure is receiving digoxin and furosemide. The c. Gather data about the events prior to the death
lab values of the pt include serum digoxin 2.9ng/mL and K+ d. Encourage the parents to join a support group
3.2mEq/L. Based on these lab results the most appropriate
nursing action is to: Answer: b. Allow the parents to say goodbye to the baby
a. Withhold the next dose of Furosemide
13. A nurse has reinforced teaching w/a client's spouse about
b. Administer an addt'l dose of digoxin
how to change the client's colostomy bag. The nurse Best
c. Notify the physician of the lab results
determines that the spouse understands the procedure by:
d. These results are w/in normal limits and require no action
a. Asking if the spouse has any questions
Answer: c. Notify the physician of the lab results b. Asking if the spouse understands what items are needed to
perform the procedure
7. A 64-year-old man is admitted to the ER w/complaints of c. Having the spouse perform the procedure and observing as
shortness of breath, heartburn, and pain in the left shoulder. the procedure is performed
After obtaining vital signs, the nurse performs a focused d. Asking if the spouse feels comfortable performing the
assessment related to the pt's: procedure
a. Heart
Answer: c. Having the spouse perform the procedure and
b. Abdomen
observing as the procedure is performed
c. Current stressors
d. Recent life changes 14. A male patient who had a pacemaker inserted relates to the
Answer: a. Heart nurse that he is apprehensive about being discharged
because he does not fully understand the pacemaker and what
8. One nursing intervention in the plan of care for a pt w/ to expect when he gets home. The most therapeutic response
paranoid personality disorder is promoting consensual by the nurse is:
validation of reality. Which nursing action is most appropriate a. "All people who have a pacemaker are concerned at first."
to implement this plan? b. "Tell me what you don't understand about your pacemaker."
a. Reinforcing the facts of the situation c. "Don't worry; I will teach you everything you need to know."
b. Encouraging verbalization of feelings d. "I will provide you with written instructions before you leave."
c. Administering antidepressant medications Answer: b. "Tell me what you don't understand about your
d. Using humor to challenge patient misperceptions pacemaker."
Answer: a. Reinforcing the facts of the situation
Page 1 of 6
, 15. A 10-year-old girl with type one diabetes receives her 27. When is the age range of Erickson's developmental stages
dinner tray. The child states that she hates broccoli and of Ego Integrity vs Despair: Answer: 65 yrs old - Death
instead wants corn on the cob. The most therapeutic response
by the nurse is: 28. What causes respiratory acidosis?
a. "Yes, but only half and Ear is allowed."
Answer: Respiratory problems; acute respiratory acidosis by
b. "No vegetable exchanges are permitted."
hypoventilation from drugs or neurological problems that
c. "Corn is considered a bread exchange." depress breathing
d. "One vegetable can be exchanged for any other vegetable."
Answer: c. "Corn is considered a bread exchange." 29. What are some signs and symptoms of respiratory
acidosis?
16. A women's labor is being augmented with Pitocin IV. Answer: Confusion, lethargy to stupor and, if not treated:
Contractions have been 2 to 3 minutes apart, lasting 60 shortness of breath, fatigue, sleepiness
seconds, and moderately firm. When palpating a patient's
abdomen, the nurse identify as a firm contraction lasting 2 1/2 30. What are the causes for respiratory alkalosis?
minutes. The nurse:
Answer: Hyperventilation resulting from prolonged
a. Turns off the Pitocin IV mechanical ventilation, high altitudes, and excessive fear
b. Increases the Pitocin IV and anxiety during pulmonary exam
c. Encourages the patient to void
d. Encourages deep breathing exercises 31. What are the signs and symptoms of respiratory alkalosis?
Answer: a. Turns off the Pitocin IV Answer: Serum pH increases; lightheadedness, dizziness,
numbness of the hands and feet, heart rate increases,
17. A patient in the cardiac unit of the hospital is diagnosed pulses weak and thready
with heart failure. The patient complains about the food, the
room temperature, and the noise on during hours of sleep. 32. What causes metabolic alkalosis?
These behaviors should cause the nurse to consider what Answer: Overuse or abusive antacids or baking soda,
factor? prolonged vomiting, or NG suctioning
a. Hypokalemia
b. Digitalis toxicity 33. What are some signs and symptoms of metabolic
c. Decreased cardiac output alkalosis?
d. Anxiety related to heart failure Answer: Related to hypokalemia which can involve
Answer: d. Anxiety related to heart failure weakness, dysrhythmias, and hypocalcemia which is related
to headache, lethargy, neuromuscular excitability
18. When a patient is receiving chemotherapy, it is important
for the nurse to assess the patient in order to implement 34. What causes metabolic acidosis?
appropriate interventions. The nurse assesses the patient for: Answer: Too much acid in the body or by too little
a. Hair loss bicarbonate. Uncontrolled diabetes, end stage renal failure,
b. Oral lesions severe diarrhea, or prolonged NG suctioning
c. Side effects of chemotherapy
d. Neutropenia 35. What are some of the signs and symptoms of metabolic
acidosis?
Answer: c. Side effects of chemotherapy
Answer: Serum pH decreases as the bicarb level decreases;
19. List in order Maslow's hierarchy of needs: confusion, lethargy, Kussmaul respirations
1st-basic physiological needs | 2nd-Safety and security | 3rd-Love
36. What is this an example of? Low pH, high or normal HCO3,
and belonging | 4th-Self-esteem | 5th-Self actualization
pCO2 high Answer: Respiratory Acidosis
20. What is the age range of Erickson's developmental stages
of Trust vs Mistrust: Answer: Birth-18 months 37. What is this an example of? High pH, low or normal HCO3,
pCO2 low Answer: Respiratory Alkalosis
21. What is the age range of Erickson's developmental stage in
Autonomy vs Shame & Doubt: Answer: 18 months-3 yrs old 38. What is this an example of? Low pH, Low HCO3, Low or
normal pCO2 Answer: Metabolic Acidosis
22. What is the age range of Erickson's developmental stages
of Initiative vs Guilt: Answer: 3-6 yrs old 39. What is this an example of? High pH, High HCO3, High or
normal pCO2 Answer: Metabolic Alkalosis
23. What is the age range of Erickson's developmental stages
of Industry vs Inferiority: Answer: 6-12 yrs old 40. An otherwise healthy individual has experienced severe
diarrhea for 36 hours. The nurse specifically will note
24. What is the age range of Erickson's developmental stages indications that the patient is experiencing:
a. Malnutrition
and Identity vs Role Confusion: Answer: 12-20 yrs old
b. Malabsorption
25. What is the age range of Erickson's developmental stages c. Metabolic alkalosis
d. Metabolic acidosis
in Intimacy vs Isolation: Answer: 20-30 yrs old
Answer: d. Metabolic acidosis
26. What is the age range of Erickson's developmental stages
of Generativity vs Stagnation: Answer: 30-65 yrs old 41. What is the normal range for pH level? Answer: 7.35-7.45
Page 2 of 6
