NCLEXvnNGNvnPre-TestvnQuestions
Avnnursevnisvnassignedvntovncarevnforvnavnclientvnwithvnchronicvnrenalvnfailurevnw
hovnisvnundergoingvnhemodialysisvnthroughvnanvninternalvnAVvnfistulavninvnthev
nRA.vnWhichvninterventionvnshouldvnthevnnursevnimplementvninvncaringvnforvnt
hevnclient?vnSATA
a.vnAssessingvnthevnradialvnpulsevninvnthevnrightvnextremity
b.vnUsingvnthevnLAvntivntakevnBPvnreadings
c.vnDrawingvnpre-dialysisvnbloodvnspecimensvnfromvnthevnLA
d.vnAssessingvnthevnareavnovervnthevnAVvnfistulavnforvnavnbruitvnandvnthreevneach
vnshift
e.vnPlacingvnavnpressurevndressingvnovervnthevnsitevnaftervneachvndialysisvntreat
ment
f.vnAdministeringvnIVvnfluidsvnthroughvnthevnvenousvnsitevnofvnthevnAVvnfistula
vnasvnneededvn-vncorrectvnanswer✔ ✔ A,vnB,vnC,vnD
AvnnursevnisvnevaluatingvnoutcomesvnforvnavnclientvnwithvnGuillain-
Barrevnsyndrome.vnWhichvnoutcomevndoesvnthevnnursevnrecognizevnasvnoptima
lvnrespiratoryvnoutcomesvnforvnthevnclient?
a.vnNormalvndeepvntendonvnreflexes
b.vnImprovedvnskeletalvnmusclevntone
c.vnAbsencesvnofvnparesthesiasvninvnthevnlowervnextremities
d.vnClearvnsoundvninvnthevnlowervnlungvnfieldsvnbilaterally
,e.vnpO2vnofvn85vnmmHgvnandvnpCO2vnofvn40vnmmHgvn-vncorrectvnanswer✔
✔ D,vnE
Avnnursevnofvnthevntelemetryvnunitvnisvncaringvnforvnavnclientvnwhovnhasvnhadvnavn
MIvnandvnisvnnowvnattachedvntovnavncardiacvnmonitor.vnThevnnursevnisvnmonitori
ngvnthevnclient'svncardiacvnrhythmvnandvnnotsvnventricularvnfibrillation.vnWhic
hvnnursingvninterventionvnshouldvnthevnnursevntakevnfirst?
a.vnCallingvnthevnrapidvnresponsevnteam
b.vnPreparingvnthevnclientvnforvncardioversion
c.vnAskingvnthevnclientvntovnbearvndownvnandvncough
d.vnPreparingvntovnadministervndiltiazemvn-vncorrectvnanswer✔ ✔ A
Thevnpatternvnofvnventricularvnfibrillationvnisvnidentifiedvnandvncanvnbevnavnresul
tvnaftervnavnpatientvnwithvnanvnMI.vnVFvnmakesvnthevnpatientvnfeelvnfaint,vnthenvnl
osesvnconsciousnessvnandvnbecomesvnpulselessvnandvnapneicvn(BPvnandvnheartv
nsoundsvnabsent).vnTreatmentvnisvntovnterminatevnVFvnandvncovertvnitvnintovnavnr
hythmvnviavndefibrillation-
>vncallvnavnrapidvnandvninitiatevnCPR.vnCardioversionvnisvnusedvnforvnventricula
rvnorvnsupraventricularvntachydysrhythmias.
Avnnursevndevelopingvnavnplanvnofvncarevnforvnavnclientvnwithvnavnspinalvncordvnin
juryvnincludesvnmeasuresvntovnpreventvnautonomicvndysreflexiavn(hyperreflex
ia).vnWhichvninterventionvndoesvnthevnnursevnincorporatevnintovnthevnplanvntovnp
reventvnthisvncomplication?
a.vnKeepingvnthevnfanvnrunningvninvnthevnclient'svnroom
b.vnKeepingvnthevnlinensvnwrinklevnfreevnundervnthevnclient
,c.vnLimitingvnbladdervncatheterizationvntovnoncevneveryvn12vnhours
d.vnAvoidingvnthevnadministrationvnofvnenemasvnandvnrectalvnsuppositoriesvn-
vncorrectvnanswer✔ ✔ B
Thevnmostvnfrequentvncausevnofvnautonomicvndysreflexiasvnarevnavndistendedvn
bladdervnandvnimpactedvnfeces.vnOthervncausesvnincludevnstimulationvnofvnthevn
skinvnbyvntactile,vnthermal,vnorvnpainfulvnstimuli.vnThevnnursevnrendersvncarevni
nvnsuchvnavnwayvnasvntovnminimizevnthesevnrisks.
Avnnursevnprovidesvnhomevncarevninstructionsvntovnavnclientvnwhovnhasvnbeenvnfi
ttedvnwithvnavnhalovndevicevntovntreatvnavncervicalvnfracture.vnWhichvnstatementv
nbyvnthevnclientvnindicatesvnthevnneedvnforvnfurthervnteaching?
a.vnIvnneedvntovngetvnmorevnfluidsvnandvnfibervnintovnmyvndiet
b.vnIvnshouldvncutvnmyvnfoodvnintovnsmallvnpiecesvnbeforevnIvneat
c.vnIvnneedvntovnputvnpowdervnundervnthevnvestvntwicevnavndayvntovnpreventvnswea
ting
d.vnIvnhavevntovncheckvnthevnpinvnsitesvneverydayvnandvnwatchvnforvnsignsvnofvninf
ectionvn-vncorrectvnanswer✔ ✔ C
Cleansevnthevnskinvnundervnthevnwoolvnlinervneachvndayvntovnpreventvnrashesvnan
dvnsoars.
Avnnursevnisvncaringvnforvnavnclientvnwithvnincreasedvnintracranialvnpressure.vnIn
vnwhichvnpositionvnshouldvnthevnnursevnmaintain vnthevnclient?
a.vnSupinevnwithvnthevnheadvnextended
b.vnSidevnlyingvnwithvnthevnneckvnflexed
, c.vnSupinevnwithvnthevnheadvnturnedvntovnthevnside
d.vnHeadvnmidlinevnandvnelevatedvn30-45vndegreesvn-vncorrectvnanswer✔ ✔
D
Propervnpositioningvnpromotesvnvenousvndrainagevnfromvnthevncraniumvntovnm
inimizevnICP.
Avnclientvnwithvnavnbasilarvnskullvnfracturevnhasvnclearvnfluidvnleakingvnfromvnth
evnears.vnThevnnursevnshouldvntakevnwhichvnactionvnfirst?
a.vnAssesvnthevnclearvnfluidvnforvnprotein
b.vnCheckvnthevnclearvnfluidvnforvnglucose
c.vnPlacevncottonvncallsvnorvndryvngauzevnlooselyvninvnthevnears
d.vnUsevnanvnotoscopevntovnassessvnthevntympanicvnmembranevnforvnrupturevn-
vncorrectvnanswer✔ ✔ B
CSFvncontainsvnglucosevnnotvnprotein.
Avnnursevnisvncaringvnforvnavnclientvnwhovnhasvnjustvnundergonevncardioversion.
vnWhichvninterventionvnisvnthevnnurse'svnpriorityvnaftervnthisvnprocedure.vn
a.vnAdministervnoxygen
b.vnMonitoringvnthevnBP
c.vnAdministeringvnantidysrhythmicvnmedications
d.vnMonitoringvnthevnclient'svnLOCvn-vncorrectvnanswer✔ ✔ A
ABC'svnofvnnursing.vnAllvnothervnchoicesvnarevncorrect,vnbutvnnotvnpriority.
Avnnursevnisvnassignedvntovncarevnforvnavnclientvnwithvnchronicvnrenalvnfailurevnw
hovnisvnundergoingvnhemodialysisvnthroughvnanvninternalvnAVvnfistulavninvnthev
nRA.vnWhichvninterventionvnshouldvnthevnnursevnimplementvninvncaringvnforvnt
hevnclient?vnSATA
a.vnAssessingvnthevnradialvnpulsevninvnthevnrightvnextremity
b.vnUsingvnthevnLAvntivntakevnBPvnreadings
c.vnDrawingvnpre-dialysisvnbloodvnspecimensvnfromvnthevnLA
d.vnAssessingvnthevnareavnovervnthevnAVvnfistulavnforvnavnbruitvnandvnthreevneach
vnshift
e.vnPlacingvnavnpressurevndressingvnovervnthevnsitevnaftervneachvndialysisvntreat
ment
f.vnAdministeringvnIVvnfluidsvnthroughvnthevnvenousvnsitevnofvnthevnAVvnfistula
vnasvnneededvn-vncorrectvnanswer✔ ✔ A,vnB,vnC,vnD
AvnnursevnisvnevaluatingvnoutcomesvnforvnavnclientvnwithvnGuillain-
Barrevnsyndrome.vnWhichvnoutcomevndoesvnthevnnursevnrecognizevnasvnoptima
lvnrespiratoryvnoutcomesvnforvnthevnclient?
a.vnNormalvndeepvntendonvnreflexes
b.vnImprovedvnskeletalvnmusclevntone
c.vnAbsencesvnofvnparesthesiasvninvnthevnlowervnextremities
d.vnClearvnsoundvninvnthevnlowervnlungvnfieldsvnbilaterally
,e.vnpO2vnofvn85vnmmHgvnandvnpCO2vnofvn40vnmmHgvn-vncorrectvnanswer✔
✔ D,vnE
Avnnursevnofvnthevntelemetryvnunitvnisvncaringvnforvnavnclientvnwhovnhasvnhadvnavn
MIvnandvnisvnnowvnattachedvntovnavncardiacvnmonitor.vnThevnnursevnisvnmonitori
ngvnthevnclient'svncardiacvnrhythmvnandvnnotsvnventricularvnfibrillation.vnWhic
hvnnursingvninterventionvnshouldvnthevnnursevntakevnfirst?
a.vnCallingvnthevnrapidvnresponsevnteam
b.vnPreparingvnthevnclientvnforvncardioversion
c.vnAskingvnthevnclientvntovnbearvndownvnandvncough
d.vnPreparingvntovnadministervndiltiazemvn-vncorrectvnanswer✔ ✔ A
Thevnpatternvnofvnventricularvnfibrillationvnisvnidentifiedvnandvncanvnbevnavnresul
tvnaftervnavnpatientvnwithvnanvnMI.vnVFvnmakesvnthevnpatientvnfeelvnfaint,vnthenvnl
osesvnconsciousnessvnandvnbecomesvnpulselessvnandvnapneicvn(BPvnandvnheartv
nsoundsvnabsent).vnTreatmentvnisvntovnterminatevnVFvnandvncovertvnitvnintovnavnr
hythmvnviavndefibrillation-
>vncallvnavnrapidvnandvninitiatevnCPR.vnCardioversionvnisvnusedvnforvnventricula
rvnorvnsupraventricularvntachydysrhythmias.
Avnnursevndevelopingvnavnplanvnofvncarevnforvnavnclientvnwithvnavnspinalvncordvnin
juryvnincludesvnmeasuresvntovnpreventvnautonomicvndysreflexiavn(hyperreflex
ia).vnWhichvninterventionvndoesvnthevnnursevnincorporatevnintovnthevnplanvntovnp
reventvnthisvncomplication?
a.vnKeepingvnthevnfanvnrunningvninvnthevnclient'svnroom
b.vnKeepingvnthevnlinensvnwrinklevnfreevnundervnthevnclient
,c.vnLimitingvnbladdervncatheterizationvntovnoncevneveryvn12vnhours
d.vnAvoidingvnthevnadministrationvnofvnenemasvnandvnrectalvnsuppositoriesvn-
vncorrectvnanswer✔ ✔ B
Thevnmostvnfrequentvncausevnofvnautonomicvndysreflexiasvnarevnavndistendedvn
bladdervnandvnimpactedvnfeces.vnOthervncausesvnincludevnstimulationvnofvnthevn
skinvnbyvntactile,vnthermal,vnorvnpainfulvnstimuli.vnThevnnursevnrendersvncarevni
nvnsuchvnavnwayvnasvntovnminimizevnthesevnrisks.
Avnnursevnprovidesvnhomevncarevninstructionsvntovnavnclientvnwhovnhasvnbeenvnfi
ttedvnwithvnavnhalovndevicevntovntreatvnavncervicalvnfracture.vnWhichvnstatementv
nbyvnthevnclientvnindicatesvnthevnneedvnforvnfurthervnteaching?
a.vnIvnneedvntovngetvnmorevnfluidsvnandvnfibervnintovnmyvndiet
b.vnIvnshouldvncutvnmyvnfoodvnintovnsmallvnpiecesvnbeforevnIvneat
c.vnIvnneedvntovnputvnpowdervnundervnthevnvestvntwicevnavndayvntovnpreventvnswea
ting
d.vnIvnhavevntovncheckvnthevnpinvnsitesvneverydayvnandvnwatchvnforvnsignsvnofvninf
ectionvn-vncorrectvnanswer✔ ✔ C
Cleansevnthevnskinvnundervnthevnwoolvnlinervneachvndayvntovnpreventvnrashesvnan
dvnsoars.
Avnnursevnisvncaringvnforvnavnclientvnwithvnincreasedvnintracranialvnpressure.vnIn
vnwhichvnpositionvnshouldvnthevnnursevnmaintain vnthevnclient?
a.vnSupinevnwithvnthevnheadvnextended
b.vnSidevnlyingvnwithvnthevnneckvnflexed
, c.vnSupinevnwithvnthevnheadvnturnedvntovnthevnside
d.vnHeadvnmidlinevnandvnelevatedvn30-45vndegreesvn-vncorrectvnanswer✔ ✔
D
Propervnpositioningvnpromotesvnvenousvndrainagevnfromvnthevncraniumvntovnm
inimizevnICP.
Avnclientvnwithvnavnbasilarvnskullvnfracturevnhasvnclearvnfluidvnleakingvnfromvnth
evnears.vnThevnnursevnshouldvntakevnwhichvnactionvnfirst?
a.vnAssesvnthevnclearvnfluidvnforvnprotein
b.vnCheckvnthevnclearvnfluidvnforvnglucose
c.vnPlacevncottonvncallsvnorvndryvngauzevnlooselyvninvnthevnears
d.vnUsevnanvnotoscopevntovnassessvnthevntympanicvnmembranevnforvnrupturevn-
vncorrectvnanswer✔ ✔ B
CSFvncontainsvnglucosevnnotvnprotein.
Avnnursevnisvncaringvnforvnavnclientvnwhovnhasvnjustvnundergonevncardioversion.
vnWhichvninterventionvnisvnthevnnurse'svnpriorityvnaftervnthisvnprocedure.vn
a.vnAdministervnoxygen
b.vnMonitoringvnthevnBP
c.vnAdministeringvnantidysrhythmicvnmedications
d.vnMonitoringvnthevnclient'svnLOCvn-vncorrectvnanswer✔ ✔ A
ABC'svnofvnnursing.vnAllvnothervnchoicesvnarevncorrect,vnbutvnnotvnpriority.
