NURS 4111- NCLEX PREP EXAM WITH
COMPLETE SOLUTIONS
respiratory acidosis - ANSWER Anything that causes a change in normal
breathing pattern (ie; obstruction of the airway or respiratory depression)
PH: LOW
PaCO2: HIGH
HCO3: NORMAL
Common causes of respiratory acidosis - ANSWER Asthma, Emphysema,
HypOventilation, Pulmonary Edema, Pneumonia, Brain Trauma & CNS
Depressants
respiratory alkalosis - ANSWER Any event that OVERstimulates the respiratory
system
PH: HIGH
PaCO2: LOW
HCO3: NORMAL
Common causes of respiratory alkalosis - ANSWER Fever, HypERventilation,
Hypoxia, pain & overventilation
metabolic acidosis - ANSWER When a condition causes a chemical imbalance in
the body which increases the body's acidity
PH: LOW
PaCO2: NORMAL
HCO3: LOW
metabolic alkalosis - ANSWER Acid loss causes an increase in the body's PH
PH: HIGH
PaCO2: NORMAL
HCO3: HIGH
Hyperkalemia ECG changes - ANSWER tall + peaked T waves, Prolonged PR
interval, ST depression, NO P wave
Hypokalemia ECG changes - ANSWER Flattened T waves, Presence of U waves,
ST depression
,Hypercalcemia ECG changes - ANSWER Widened T waves, Shortened ST
intervals, Shortened QT intervals
Hypocalcemia - ANSWER Prolonged ST+ QR intervals
The nurse has been made aware of the following client situations. The nurse
should first assess the client:
A) With diverticulitis who is reporting left lower quadrant (LLQ) pain
B) With chronic obstructive pulmonary disease who is reporting hemoptysis
C) Who had an evacuation of a subdural hematoma 8 hours ago and has become
agitated
D) Who had a total knee replacement 8 hours ago who affected extremity is
internally rotated - ANSWER C
The nurse is assigning unlicensed assistive personnel (UAP) to assist with the
following clients to ambulate. It would be most important for the nurse to review
safety precautions with the UAP prior to ambulation the:
a) 59-year old with a unilateral cataract
b) 44-year old with Meniere's disease (Meniere's disease = vertigo)
c) 62-year old client with presbycusis (e.g., loss of hearing)
d) 65-year old client with sinusitis - ANSWER b
The nurse is teaching clients at a community health fair about risk factors for
developing cancer. The nurse should recognize that at highest risk is the
a) 30-year-old client who consumes a diet high in selenium and has a history of
an ovarian cyst
b) 49-year-old client who drinks 2 to 3 cups of coffee daily and has a family
history of fibrocystic breast conditions
c) 51-year-old client who has hypertension and teaches an aerobic exercise
program
d) 62-year-old client who consumes 5 to 6 alcoho - ANSWER D
The nurse is talking with a client who had a colostomy 2 days ago. Which of the
following statements by the client would indicate ineffective coping? Select all
that apply.
a) "I am not touching that disgusting bag."
b) "I am glad that I can still go to the gym just as I used to."
c) "I really like raw vegetables, and it will be hard for me to eliminate them."
d) "I understand the need for the colostomy, but I am afraid that the bag will
leak."
e) "I don't understand why I ca - ANSWER a, e
The nurse is preparing to administer prescribed otic drops to a 1-year-old client.
Which of the following actions should the nurse take?
Gently pull the pinna upward and straight back to straighten the auditory canal.
, a) Administer the drops immediately after removing them from the refrigerator
to minimize the risk of bacterial growth.
b) Direct the drops along the side of the ear canal to avoid instilling the
medication directly onto the eardrum.
c) Gently massage the area immediately poster - ANSWER b
5 phases of the nursing process. which is ALWAYS first? - ANSWER 1.
Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
When do paediatric fontanelles close (posterior and anterior) - ANSWER
Posterior: 8 weeks
Anterior: 18 months
Caput succedaneum - ANSWER "cone head" swelling of infants scalp shortly
after birth
Cephalohematoma - ANSWER bleeding between the osteum and periosteum of
the skull. This swelling does not cross suture lines.
barral chest - ANSWER a deformity in which the chest becomes expanded in size
When is JVD visible? - ANSWER JVD > 4cm or venous distension remains visible
when HOB @ 45 degrees
S1 - ANSWER the first heart sound, heard when the atrioventricular (mitral and
tricuspid) valves close
S2 - ANSWER the second heart sound, heard when the semilunar (aortic and
pulmonic) valves close
What is the sound of a murmur - ANSWER Turbulent blood flow
Bruit - ANSWER blowing, swooshing sound heard through a stethoscope when
an artery is partially occluded
Blumberg's sign - ANSWER pain upon release of palpation pressure (peritoneal
inflammation)
Murphy's sign - ANSWER pain when client asked to breathe in while hand is
placed below right costal margin (gallbladder inflammation)
McBurney's point - ANSWER RLQ pain (appendicitis)
COMPLETE SOLUTIONS
respiratory acidosis - ANSWER Anything that causes a change in normal
breathing pattern (ie; obstruction of the airway or respiratory depression)
PH: LOW
PaCO2: HIGH
HCO3: NORMAL
Common causes of respiratory acidosis - ANSWER Asthma, Emphysema,
HypOventilation, Pulmonary Edema, Pneumonia, Brain Trauma & CNS
Depressants
respiratory alkalosis - ANSWER Any event that OVERstimulates the respiratory
system
PH: HIGH
PaCO2: LOW
HCO3: NORMAL
Common causes of respiratory alkalosis - ANSWER Fever, HypERventilation,
Hypoxia, pain & overventilation
metabolic acidosis - ANSWER When a condition causes a chemical imbalance in
the body which increases the body's acidity
PH: LOW
PaCO2: NORMAL
HCO3: LOW
metabolic alkalosis - ANSWER Acid loss causes an increase in the body's PH
PH: HIGH
PaCO2: NORMAL
HCO3: HIGH
Hyperkalemia ECG changes - ANSWER tall + peaked T waves, Prolonged PR
interval, ST depression, NO P wave
Hypokalemia ECG changes - ANSWER Flattened T waves, Presence of U waves,
ST depression
,Hypercalcemia ECG changes - ANSWER Widened T waves, Shortened ST
intervals, Shortened QT intervals
Hypocalcemia - ANSWER Prolonged ST+ QR intervals
The nurse has been made aware of the following client situations. The nurse
should first assess the client:
A) With diverticulitis who is reporting left lower quadrant (LLQ) pain
B) With chronic obstructive pulmonary disease who is reporting hemoptysis
C) Who had an evacuation of a subdural hematoma 8 hours ago and has become
agitated
D) Who had a total knee replacement 8 hours ago who affected extremity is
internally rotated - ANSWER C
The nurse is assigning unlicensed assistive personnel (UAP) to assist with the
following clients to ambulate. It would be most important for the nurse to review
safety precautions with the UAP prior to ambulation the:
a) 59-year old with a unilateral cataract
b) 44-year old with Meniere's disease (Meniere's disease = vertigo)
c) 62-year old client with presbycusis (e.g., loss of hearing)
d) 65-year old client with sinusitis - ANSWER b
The nurse is teaching clients at a community health fair about risk factors for
developing cancer. The nurse should recognize that at highest risk is the
a) 30-year-old client who consumes a diet high in selenium and has a history of
an ovarian cyst
b) 49-year-old client who drinks 2 to 3 cups of coffee daily and has a family
history of fibrocystic breast conditions
c) 51-year-old client who has hypertension and teaches an aerobic exercise
program
d) 62-year-old client who consumes 5 to 6 alcoho - ANSWER D
The nurse is talking with a client who had a colostomy 2 days ago. Which of the
following statements by the client would indicate ineffective coping? Select all
that apply.
a) "I am not touching that disgusting bag."
b) "I am glad that I can still go to the gym just as I used to."
c) "I really like raw vegetables, and it will be hard for me to eliminate them."
d) "I understand the need for the colostomy, but I am afraid that the bag will
leak."
e) "I don't understand why I ca - ANSWER a, e
The nurse is preparing to administer prescribed otic drops to a 1-year-old client.
Which of the following actions should the nurse take?
Gently pull the pinna upward and straight back to straighten the auditory canal.
, a) Administer the drops immediately after removing them from the refrigerator
to minimize the risk of bacterial growth.
b) Direct the drops along the side of the ear canal to avoid instilling the
medication directly onto the eardrum.
c) Gently massage the area immediately poster - ANSWER b
5 phases of the nursing process. which is ALWAYS first? - ANSWER 1.
Assessment
2. Diagnosis
3. Planning
4. Implementation
5. Evaluation
When do paediatric fontanelles close (posterior and anterior) - ANSWER
Posterior: 8 weeks
Anterior: 18 months
Caput succedaneum - ANSWER "cone head" swelling of infants scalp shortly
after birth
Cephalohematoma - ANSWER bleeding between the osteum and periosteum of
the skull. This swelling does not cross suture lines.
barral chest - ANSWER a deformity in which the chest becomes expanded in size
When is JVD visible? - ANSWER JVD > 4cm or venous distension remains visible
when HOB @ 45 degrees
S1 - ANSWER the first heart sound, heard when the atrioventricular (mitral and
tricuspid) valves close
S2 - ANSWER the second heart sound, heard when the semilunar (aortic and
pulmonic) valves close
What is the sound of a murmur - ANSWER Turbulent blood flow
Bruit - ANSWER blowing, swooshing sound heard through a stethoscope when
an artery is partially occluded
Blumberg's sign - ANSWER pain upon release of palpation pressure (peritoneal
inflammation)
Murphy's sign - ANSWER pain when client asked to breathe in while hand is
placed below right costal margin (gallbladder inflammation)
McBurney's point - ANSWER RLQ pain (appendicitis)
