Archer Nclex day 1
A client is scheduled for gastroscopy at 8:00 AM and has been placed on NPO since midnight.
At 6:30 AM, the nurse checks the client's capillary blood glucose level and gets a result of 40
mg/dl on the glucometer. The client is alert, coherent, and reports, "I feel fine. I don't feel
anything." The most appropriate action for the nurse is:
A. Record the finding in the notes and withhold the client's morning insulin.
B. Take a repeat sample of the capillary blood glucose.
C. Give the client simple sugar by mouth.
D. Administer intravenous dextrose 50 grams STAT. - ANSChoice B is correct. The nurse should
repeat the test because the client does not display any symptoms of hypoglycemia. The
glucometer readings are not always accurate. Many variables such as quality of blood sample,
dirt on the meter, humidity, aged test strip, high hematocrit etc. may affect glucometer readings.
In view of so many variables affecting the blood glucose reading in glucometer, the nurse must
be alert while interpreting these values especially, in the absence of any symptoms.
Definition of hypoglycemia differs in diabetic patients differs from that of non-diabetic patients. In
diabetic patients, Hypoglycemia is defined as a blood glucose of less than 70mg/dl. Many
diabetics may also have a condition called "Hypoglycemia unawareness" where there may not
be sufficient autonomic warning symptoms before the onset of neuroglycopenia (impaired
cognition, coma). In a diabetic patient, therefore, hypoglycemia needs to be treated as soon as
possible based on the lab values even in the absence of overt symptoms.
In non-diabetic adults with low glucose level, one should assess for symptoms. Symptoms may
include cold, clammy skin, tachycardia, palpitations, impaired cognition, slurred speech,
seizures, and confusion. A low blood glucose at the time of symptoms and improvement as
soon as the blood glucose returns to normal confirm the diagnosis. In a non-diabetic client who
has been fasting, a blood glucose less than 50 mg/dL can also be used to define hypoglycemia.
In the absence of symptoms, however, the first step is to recheck the blood glucose and confirm
the result.
Choice A is incorrect. Because the first reading was too low, it is appropriate for the nurse to
recheck before documenting the findings to confirm accuracy.
Choice C is incorrect. The nurse should recheck and validate the results before deciding
The nurse is obtaining consent for surgery from a client. What should be the initial action of the
nurse while obtaining consent?
A. Determine if the client has sufficient knowledge about the procedure.
B. Witness the signature of the client.
C. Tell the client that obtaining a signature is routine prior to surgery.
,D. Explain the risks involved in the surgery. - ANSChoice A is correct. "Informed" consent
means that the client must understand the procedure, the alternative options, and the risks and
consequences involved. The nurse should make sure that the client has sufficient knowledge
about the procedure before asking him to sign a consent.
While it is crucial for the client to know the risks of the procedure before signing the consent,
those risks should be explained to the client by the doctor, not the nurse.
Choice B is incorrect. The nurse should first assess the client's understanding of the
surgery/procedure before signing as a witness.
Choice C is incorrect. Procuring the client's signature for consent is routine before the surgery.
However, just telling this to the client does not satisfy the client's right to informed consent.
Choice D is incorrect. Explaining the procedural risks involved is not the nurse's responsibility
and should be done by the doctor.
Which ergonomically designed work tool can prevent repetitive stress syndrome?
A. A back support belt
B. A special computer mouse
C. A special chair for sitting
D. Weighted pens and pencils - ANSCorrect Answer is B. A special ergonomically designed
work tool that can prevent repetitive stress syndrome, which is also referred to as carpal tunnel
syndrome, is a special computer mouse.
Choice A is incorrect. A back support belt is a protective device that may help to avoid a back
injury and not repetitive stress syndrome.
Choice C is incorrect. A special chair for sitting in correct posture prevents muscle fatigue and
maintains the body in the correct alignment with lumbar support, but it does not prevent
repetitive stress syndrome.
Choice D is incorrect. Weighted pens and pencils may be used by clients with poor fine motor
coordination, but they do not prevent repetitive stress syndrome.
Case management, as a form of patient care delivery and documentation, is most closely
aligned with:
A. The SOAP method of documentation
B. The SOAPIE method of documentation
C. Variances
D. Case mix - ANSCorrect Answer is C. Variances, including patient variances, system
variances and practitioner variances are deviations from the expected plan of care and
, treatment that is documented on the critical pathway of the case management method of patient
care delivery and documentation.
Choice A is incorrect. The SOAP method of documentation is part of the problem-oriented
medical record documentation system and not the case management method of patient care
delivery and documentation.
Choice B is incorrect. The SOAPIE method of documentation is part of the problem-oriented
medical record documentation system and not the case management method of patient care
delivery and documentation.
Choice D is incorrect. Case-mix reflects the collective conditions of the clients and it is not part
of the case management method of patient care delivery and documentation.
The obstetric nurse is reading the prenatal client's chart. The nurse notes that the patient is
suffering from preeclampsia and knows to observe for which complications in the newborn?
A. Shaking and agitation
B. Low birth-weight
C. Abnormal kidney function
D. Blurred vision - ANSThe correct answer is B. The nurse with this patient should expect an
infant born with low birth weight. Preeclampsia often results in blood being shunted away from
the fetus; growth restriction is commonly found in infants born to these women.
Choice A is incorrect. Shaking and agitation aren't commonly connected with preeclampsia.
These symptoms may be related to drug abuse or gestational diabetes.
Choice C and D are incorrect. Blurred vision and abnormal kidney function affect mothers who
are suffering from preeclampsia, not their infants.
The nurse is caring for a patient receiving a blood transfusion. On assessment, the nurse notes
that the patient's respirations are rapid, the face is flushed, and the patient is complaining of
itching. The nurse suspects the patient is having a transfusion reaction. The nurse should
accomplish the following actions:
The nurse should complete the tasks in the following order:
A. Take vital signs
B. Stop the transfusion
C. Administer oxygen
D. Obtain a urine specimen.
The nurse should complete the tasks in the following order: - ANSB, C,A,D
Correct Answer is:
A client is scheduled for gastroscopy at 8:00 AM and has been placed on NPO since midnight.
At 6:30 AM, the nurse checks the client's capillary blood glucose level and gets a result of 40
mg/dl on the glucometer. The client is alert, coherent, and reports, "I feel fine. I don't feel
anything." The most appropriate action for the nurse is:
A. Record the finding in the notes and withhold the client's morning insulin.
B. Take a repeat sample of the capillary blood glucose.
C. Give the client simple sugar by mouth.
D. Administer intravenous dextrose 50 grams STAT. - ANSChoice B is correct. The nurse should
repeat the test because the client does not display any symptoms of hypoglycemia. The
glucometer readings are not always accurate. Many variables such as quality of blood sample,
dirt on the meter, humidity, aged test strip, high hematocrit etc. may affect glucometer readings.
In view of so many variables affecting the blood glucose reading in glucometer, the nurse must
be alert while interpreting these values especially, in the absence of any symptoms.
Definition of hypoglycemia differs in diabetic patients differs from that of non-diabetic patients. In
diabetic patients, Hypoglycemia is defined as a blood glucose of less than 70mg/dl. Many
diabetics may also have a condition called "Hypoglycemia unawareness" where there may not
be sufficient autonomic warning symptoms before the onset of neuroglycopenia (impaired
cognition, coma). In a diabetic patient, therefore, hypoglycemia needs to be treated as soon as
possible based on the lab values even in the absence of overt symptoms.
In non-diabetic adults with low glucose level, one should assess for symptoms. Symptoms may
include cold, clammy skin, tachycardia, palpitations, impaired cognition, slurred speech,
seizures, and confusion. A low blood glucose at the time of symptoms and improvement as
soon as the blood glucose returns to normal confirm the diagnosis. In a non-diabetic client who
has been fasting, a blood glucose less than 50 mg/dL can also be used to define hypoglycemia.
In the absence of symptoms, however, the first step is to recheck the blood glucose and confirm
the result.
Choice A is incorrect. Because the first reading was too low, it is appropriate for the nurse to
recheck before documenting the findings to confirm accuracy.
Choice C is incorrect. The nurse should recheck and validate the results before deciding
The nurse is obtaining consent for surgery from a client. What should be the initial action of the
nurse while obtaining consent?
A. Determine if the client has sufficient knowledge about the procedure.
B. Witness the signature of the client.
C. Tell the client that obtaining a signature is routine prior to surgery.
,D. Explain the risks involved in the surgery. - ANSChoice A is correct. "Informed" consent
means that the client must understand the procedure, the alternative options, and the risks and
consequences involved. The nurse should make sure that the client has sufficient knowledge
about the procedure before asking him to sign a consent.
While it is crucial for the client to know the risks of the procedure before signing the consent,
those risks should be explained to the client by the doctor, not the nurse.
Choice B is incorrect. The nurse should first assess the client's understanding of the
surgery/procedure before signing as a witness.
Choice C is incorrect. Procuring the client's signature for consent is routine before the surgery.
However, just telling this to the client does not satisfy the client's right to informed consent.
Choice D is incorrect. Explaining the procedural risks involved is not the nurse's responsibility
and should be done by the doctor.
Which ergonomically designed work tool can prevent repetitive stress syndrome?
A. A back support belt
B. A special computer mouse
C. A special chair for sitting
D. Weighted pens and pencils - ANSCorrect Answer is B. A special ergonomically designed
work tool that can prevent repetitive stress syndrome, which is also referred to as carpal tunnel
syndrome, is a special computer mouse.
Choice A is incorrect. A back support belt is a protective device that may help to avoid a back
injury and not repetitive stress syndrome.
Choice C is incorrect. A special chair for sitting in correct posture prevents muscle fatigue and
maintains the body in the correct alignment with lumbar support, but it does not prevent
repetitive stress syndrome.
Choice D is incorrect. Weighted pens and pencils may be used by clients with poor fine motor
coordination, but they do not prevent repetitive stress syndrome.
Case management, as a form of patient care delivery and documentation, is most closely
aligned with:
A. The SOAP method of documentation
B. The SOAPIE method of documentation
C. Variances
D. Case mix - ANSCorrect Answer is C. Variances, including patient variances, system
variances and practitioner variances are deviations from the expected plan of care and
, treatment that is documented on the critical pathway of the case management method of patient
care delivery and documentation.
Choice A is incorrect. The SOAP method of documentation is part of the problem-oriented
medical record documentation system and not the case management method of patient care
delivery and documentation.
Choice B is incorrect. The SOAPIE method of documentation is part of the problem-oriented
medical record documentation system and not the case management method of patient care
delivery and documentation.
Choice D is incorrect. Case-mix reflects the collective conditions of the clients and it is not part
of the case management method of patient care delivery and documentation.
The obstetric nurse is reading the prenatal client's chart. The nurse notes that the patient is
suffering from preeclampsia and knows to observe for which complications in the newborn?
A. Shaking and agitation
B. Low birth-weight
C. Abnormal kidney function
D. Blurred vision - ANSThe correct answer is B. The nurse with this patient should expect an
infant born with low birth weight. Preeclampsia often results in blood being shunted away from
the fetus; growth restriction is commonly found in infants born to these women.
Choice A is incorrect. Shaking and agitation aren't commonly connected with preeclampsia.
These symptoms may be related to drug abuse or gestational diabetes.
Choice C and D are incorrect. Blurred vision and abnormal kidney function affect mothers who
are suffering from preeclampsia, not their infants.
The nurse is caring for a patient receiving a blood transfusion. On assessment, the nurse notes
that the patient's respirations are rapid, the face is flushed, and the patient is complaining of
itching. The nurse suspects the patient is having a transfusion reaction. The nurse should
accomplish the following actions:
The nurse should complete the tasks in the following order:
A. Take vital signs
B. Stop the transfusion
C. Administer oxygen
D. Obtain a urine specimen.
The nurse should complete the tasks in the following order: - ANSB, C,A,D
Correct Answer is:
