NCLEX-RN EXIT EXAM STUDY GUIDE; HIGH-YIELD
PRACTICE QUESTIONS, VERIFIED CORRECT
ANSWERS, NURSING MNEMONICS & CLINICAL
LABORATORY VALUES (GRADED A+)
Endometiral infection usually occurs - Correct Answers--with a prolonged rupture of
membranes, not vacuum-assisted births.
Intenstinal gas is a common side effect of - Correct Answers--clients following a
cesarean birth
Cervical lacerations are common complications from - Correct Answers--vacuum-
assisted birth are rare but can include perineal, vaginal, or cervical lacerations
When a client is experiencing a wound evisceration... - Correct Answers--the nurse
should initially stay with the client and call for help. Next, the nurse should place saline-
soaked gauze on the exposed bowels to keep the internal organs moist. The nurse
should then place the client in a supine position with his hips and knees bent to relieve
pressure from the open wound. Last, the nurse should take the client's vital signs to
assess for changes in hemodynamics.
Valproic acid can cause - Correct Answers--hepatic toxicity
continuous passive motion (CPM) machine - Correct Answers--Turn of the CPM
machine during meals to promote comfort and dietary intake.
-The affected extremity should maintain neutral alignment.
,Heparin - Correct Answers--is an anticoagulant that inhibits the conversation of
prothrombin to thrombin. Patients on an anticoagulant drug such as heparin are at an
increased risk of bleeding.
-Signs of bleeding: ecchymoses, tarry stools, mucosal bleeding, and pink/ red-tinged
urine.
Correct method for walking upstairs with crutches - Correct Answers--1. Hold to rail with
one hand and crutches with the other hand.
2. Push down on the stair rail and the crutches and step up with the "unaffected" leg.
3. If not allowed to place weight on the "affected" leg, hop up with the "unaffected" leg.
4. Bring the "affected" leg and the crutches up beside the "unaffected" leg.
5. Remember, the "unaffected" leg goes up first and the crutches move with the "affected"
leg.
Droplet precautions - Correct Answers--DROPLET: "SPIDERMAn"
-Sepsis
-Scarlet Fever
-Strep
-Pertussis
-Pneumonia
-Parvovirus
-Influenza
-Diphtheria
-Epiglottitis
-Rubella
-Mumps
,-Adenovirus
Management: Private room/mask
-A private room a rom with other clients with the same infectious disease.
-Masks for providers and visitors
Airborne precautions: - Correct Answers--AIRBORNE: "My Chicken Hez TB"
-Measles
-Chicken pox
-Herpes zoster
-TB
Management: neg. pressure room, private room, mask, n-95 for TB.
-A private room
-Masks or respiratory protection devices for caregivers and visitors.
-An N95 or high-efficiency particulate air (HEPA) respirator is used if the client is known
or suspected to have TB.
-Negative pressure airflow exchange in the room of at least six exchanges per hour.
Contact precautions - Correct Answers--CONTACT: "MRS WEE"
-MRSA
-RSV
, -Skin infections (herpes zoster, cutaneous diphtheria, impetigo, pediculosis, scabies, and
staph)
-Wound infections
-Enteric infections (C-Diff)
-Eye infections (conjunctivitis)
Management: gown, gloves, goggles, private room
VRSA - contact and airborne precautions (private room, door closed, negative pressure)
-A private room or a room with other clients with the same infection.
-Gloves and gowns worn by the caregivers and visitors.
Stage I pressure ulcer - Correct Answers--Intact skin with an area of persistent,
nonblanchable redness, typically over a bony prominence, that may feel warmer or
cooler than the adjacent tissue. The tissue is swollen and has congestion, with
possible discomfort at the site. With darker skin tones, the ulcer may appear blue or
purple.
Stage II pressure ulcer - Correct Answers--Partial-thickness skin loss involving the
epidermis and the dermis. The ulcer is visible and superficial and may appear as an
abrasion, blister, or shallow crater. Edema persists, and the ulcer may become infected,
possibly with pain and scant drainage.
Stage III pressure ulcer - Correct Answers--Full-thickness tissue loss with damage to or
necrosis of subcutaneous tissue. The ulcer may extend down to, but not through,
underlying fascia. The ulcer appears as a deep crater with or without undermining of
adjacent tissue and without exposed muscle or bone. Drainage and infection are
common.
Stage IV pressure ulcer - Correct Answers--Full-thickness tissue loss with destruction,
tissue necrosis, or damage to muscle, bone, or supporting structures. There may be
sinus tracts, deep