NCLEX-PN Archer Exam with verified |!| |!| |!| |!| |!|
solutions
The nurse is caring for a client receiving Lorazepam. Which of the
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
following reported herbal supplements would require follow-up? Select all
|!| |!| |!| |!| |!| |!| |!| |!| |!|
that apply |!| |!|
1) Kava
|!|
2) Glucosamine
|!| |!|
3) Valerian
|!| |!|
4) Garlic
|!| |!|
5) Saw palmetto - correct answer✔✔1 and 3 are correct.
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
Lorazepam is a CNS depressant, and the client should avoid potentiating
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
the effects of this medication. Herbal products such as Kava and Valerian
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
are CNS depressant medications that should not be given concurrently
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
while a client receives Lorazepam. Lorazepam and one of these
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
medications may cause profound sedation. |!| |!| |!| |!|
What is the correct order for a Metered Dose Inhaler (MDI) without a
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
spacer? - correct answer✔✔Remove the inhaler cap and shake the inhaler
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
Open your mouth and place the mouthpiece 1 to 2 inches away from the
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
mouth.
Tilt your head back and breathe out fully
|!| |!| |!| |!| |!| |!| |!| |!|
Press down firmly on the canister and breathe deeply through the mouth
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
Hold your breath for at least 10 seconds
|!| |!| |!| |!| |!| |!| |!|
Wait at least 1 minute between puffs
|!| |!| |!| |!| |!| |!|
,The nurse needs to obtain baseline ____ prior to administering atenolol
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
because atenolol would be contraindicated if the client ____. - correct
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
answer✔✔The nurse needs to obtain baseline electrocardiogram prior to |!| |!| |!| |!| |!| |!| |!| |!| |!|
administering atenolol because atenolol would be contraindicated if the |!| |!| |!| |!| |!| |!| |!| |!| |!|
client had atrioventricular block.
|!| |!| |!|
The nurse understands that the prescribed fenofibrate is intended to ___. -
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
correct answer✔✔Reduce triglycerides
|!| |!|
Prior to administering the prescribed pitavastatin, the nurse needs to
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
obtain baseline ____. - correct answer✔✔liver function tests
|!| |!| |!| |!| |!| |!| |!|
The nurse is caring for a client who sustained a fractured tibia and fibula
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
and has a cast applied to the extremity. Which of the following findings
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
would indicate the client has developed compartment syndrome?
|!| |!| |!| |!| |!| |!| |!| |!|
1) the development of petechiae over the chest
|!| |!| |!| |!| |!| |!| |!| |!|
2) a new onset of dyspnea and chest pain
|!| |!| |!| |!| |!| |!| |!| |!|
3) severe pain that is unrelieved by an opioid analgesic
|!| |!| |!| |!| |!| |!| |!| |!| |!|
4) localized bone pain with a fever - correct answer✔✔C is correct.
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
Early manifestations associated with compartment syndrome, including
|!| |!| |!| |!| |!| |!| |!|
paresthesia of the affected extremity and pain unrelieved by a prescribed
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
opioid analgesic. |!|
To promote home safety for a client with epilepsy, the nurse should
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
recommend the following - correct answer✔✔Remove scatter rugs and |!| |!| |!| |!| |!| |!| |!| |!| |!|
frayed carpet, cover rooms with wall-wall carpeting
|!| |!| |!| |!| |!| |!| |!|
Edges of countertops are padded
|!| |!| |!| |!|
Medic-alert tag is worn by the client while at home |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
Knives are removed, and meals should be chopped using a food processor
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
, Microwaving food is safer than using a stove |!| |!| |!| |!| |!| |!| |!|
showering in a bathroom that is unlocked is recommened |!| |!| |!| |!| |!| |!| |!| |!|
shower chair with a wand should be used. The client should not take a
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
bath because of the risk of drowning.
|!| |!| |!| |!| |!| |!| |!|
seizure-safe pillows should be used to prevent asphyxiation |!| |!| |!| |!| |!| |!| |!|
When collecting data about a client's pain, the first step in pain
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
assessment is for the nurse to: |!| |!| |!| |!| |!| |!|
1) Accept the client's report of pain
|!| |!| |!| |!| |!| |!| |!|
2) Get the discription of the location and intensity of the pain
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
3) Have the client identifying coping methods
|!| |!| |!| |!| |!| |!| |!|
4) determine the client's status of pain - correct answer✔✔Accept the
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
client's report of pain |!| |!| |!| |!|
Assessment of pain is a vital part of any nursing assessment. In fact, pain |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
is often called the "fifth vital sign". If a patient does not immedately report
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
pain, it is still the nurse's responsibility to ask if he/she feels any pain. if
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
the patient reports pain (under any circumstances), the nurse should
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
validate the patient's concern by acknowledging he/she is feeling
|!| |!| |!| |!| |!| |!| |!| |!| |!|
discomfort and then assess more thoroughly to find out the location and
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
intensity, identifying coping mechanisms, and follow up with their pain
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
status.
Which of the following is least likely to influence a client's potential to
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
comply with lithium therapy after discharge?
|!| |!| |!| |!| |!| |!|
1) The impact of lithium on the client's energy level
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
2) The need for consistent blood level monitoring
|!| |!| |!| |!| |!| |!| |!| |!|
3) The potential side effects of lithium
|!| |!| |!| |!| |!| |!| |!|
solutions
The nurse is caring for a client receiving Lorazepam. Which of the
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
following reported herbal supplements would require follow-up? Select all
|!| |!| |!| |!| |!| |!| |!| |!| |!|
that apply |!| |!|
1) Kava
|!|
2) Glucosamine
|!| |!|
3) Valerian
|!| |!|
4) Garlic
|!| |!|
5) Saw palmetto - correct answer✔✔1 and 3 are correct.
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
Lorazepam is a CNS depressant, and the client should avoid potentiating
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
the effects of this medication. Herbal products such as Kava and Valerian
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
are CNS depressant medications that should not be given concurrently
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
while a client receives Lorazepam. Lorazepam and one of these
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
medications may cause profound sedation. |!| |!| |!| |!|
What is the correct order for a Metered Dose Inhaler (MDI) without a
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
spacer? - correct answer✔✔Remove the inhaler cap and shake the inhaler
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
Open your mouth and place the mouthpiece 1 to 2 inches away from the
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
mouth.
Tilt your head back and breathe out fully
|!| |!| |!| |!| |!| |!| |!| |!|
Press down firmly on the canister and breathe deeply through the mouth
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
Hold your breath for at least 10 seconds
|!| |!| |!| |!| |!| |!| |!|
Wait at least 1 minute between puffs
|!| |!| |!| |!| |!| |!|
,The nurse needs to obtain baseline ____ prior to administering atenolol
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
because atenolol would be contraindicated if the client ____. - correct
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
answer✔✔The nurse needs to obtain baseline electrocardiogram prior to |!| |!| |!| |!| |!| |!| |!| |!| |!|
administering atenolol because atenolol would be contraindicated if the |!| |!| |!| |!| |!| |!| |!| |!| |!|
client had atrioventricular block.
|!| |!| |!|
The nurse understands that the prescribed fenofibrate is intended to ___. -
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
correct answer✔✔Reduce triglycerides
|!| |!|
Prior to administering the prescribed pitavastatin, the nurse needs to
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
obtain baseline ____. - correct answer✔✔liver function tests
|!| |!| |!| |!| |!| |!| |!|
The nurse is caring for a client who sustained a fractured tibia and fibula
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
and has a cast applied to the extremity. Which of the following findings
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
would indicate the client has developed compartment syndrome?
|!| |!| |!| |!| |!| |!| |!| |!|
1) the development of petechiae over the chest
|!| |!| |!| |!| |!| |!| |!| |!|
2) a new onset of dyspnea and chest pain
|!| |!| |!| |!| |!| |!| |!| |!|
3) severe pain that is unrelieved by an opioid analgesic
|!| |!| |!| |!| |!| |!| |!| |!| |!|
4) localized bone pain with a fever - correct answer✔✔C is correct.
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
Early manifestations associated with compartment syndrome, including
|!| |!| |!| |!| |!| |!| |!|
paresthesia of the affected extremity and pain unrelieved by a prescribed
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
opioid analgesic. |!|
To promote home safety for a client with epilepsy, the nurse should
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
recommend the following - correct answer✔✔Remove scatter rugs and |!| |!| |!| |!| |!| |!| |!| |!| |!|
frayed carpet, cover rooms with wall-wall carpeting
|!| |!| |!| |!| |!| |!| |!|
Edges of countertops are padded
|!| |!| |!| |!|
Medic-alert tag is worn by the client while at home |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
Knives are removed, and meals should be chopped using a food processor
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
, Microwaving food is safer than using a stove |!| |!| |!| |!| |!| |!| |!|
showering in a bathroom that is unlocked is recommened |!| |!| |!| |!| |!| |!| |!| |!|
shower chair with a wand should be used. The client should not take a
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
bath because of the risk of drowning.
|!| |!| |!| |!| |!| |!| |!|
seizure-safe pillows should be used to prevent asphyxiation |!| |!| |!| |!| |!| |!| |!|
When collecting data about a client's pain, the first step in pain
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
assessment is for the nurse to: |!| |!| |!| |!| |!| |!|
1) Accept the client's report of pain
|!| |!| |!| |!| |!| |!| |!|
2) Get the discription of the location and intensity of the pain
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
3) Have the client identifying coping methods
|!| |!| |!| |!| |!| |!| |!|
4) determine the client's status of pain - correct answer✔✔Accept the
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
client's report of pain |!| |!| |!| |!|
Assessment of pain is a vital part of any nursing assessment. In fact, pain |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
is often called the "fifth vital sign". If a patient does not immedately report
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
pain, it is still the nurse's responsibility to ask if he/she feels any pain. if
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
the patient reports pain (under any circumstances), the nurse should
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
validate the patient's concern by acknowledging he/she is feeling
|!| |!| |!| |!| |!| |!| |!| |!| |!|
discomfort and then assess more thoroughly to find out the location and
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
intensity, identifying coping mechanisms, and follow up with their pain
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
status.
Which of the following is least likely to influence a client's potential to
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
comply with lithium therapy after discharge?
|!| |!| |!| |!| |!| |!|
1) The impact of lithium on the client's energy level
|!| |!| |!| |!| |!| |!| |!| |!| |!| |!|
2) The need for consistent blood level monitoring
|!| |!| |!| |!| |!| |!| |!| |!|
3) The potential side effects of lithium
|!| |!| |!| |!| |!| |!| |!|
