KAPLAN NURSING: EXIT PREPARATIONS AND N-CLEX
EXAM [450] QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES| ALREADY GRADED A+
Z-Track method - ANSWER - It reduces irritation to the subcutaneous and skin
tissues
Milieu therapy - ANSWER - Provide a consistent set of activities and
responsibilities for each client
Alzheimer's disease (AD) - ANSWER - A progressive disease that destroys the
brain's neurons, gradually impairing memory, thinking, language, and other
cognitive functions, resulting in the complete inability to care for oneself; the most
common cause of dementia.
-Temperature extremes or excessive noise can agitate the client and trigger
behavior changes.
Which client can assign to the New nurse - ANSWER - A client with a chronic
condition who is awaiting discharge
Amikacin - ANSWER - -An aminoglycoside antibiotic
-can cause nausea and diarrhea
-can cause nephrotoxicity and ototoxicity
-contraindicated with renal damage
-can potentiate the action of warfarin
Panic attacks - ANSWER - -the client is pacing, hyperventilating, and unable to
follow instructions
1
,-stay with the client
Vaccine guidelines for a 2 months old - ANSWER - -rotavirus
-diphtheria, tetanus, and pertussis
-Haemophilus influenzae (HIB)
Poliovirus
-streptococcus pneumonia
Hemolytic reactions - ANSWER - When happened
-the infusion should be stopped if hematuria occurs
-stopping it immediately
-follow facility protocol
Alcohol withdrawal symptoms - ANSWER - Hyperalertness, easily startled,
anorexia, tremors, increased pulse, and anxiety.
food pocketing - ANSWER - A client who pocketed food has a high priority
because the client is at risk for aspiration
Client under legal guardianship - ANSWER - Client under legal guardianship have
lost mental competence to make medical decisions for themselves
Rh factor incompatibility - ANSWER - Required attention but only if:
-mother is Rh-negative and baby Rh-Positive
ABO incompatibility - ANSWER - Mother's blood type is O
2
,Infant's blood type is A, B, or AB
Dissociative disorders - ANSWER - The client said " I don't know who I am or
where I live "
-sudden or gradual disruption in the integration function of identity, memory, or
consciousness
A client said "I was raped last night " - ANSWER - -reassure the client of being in
a place
Because rape is a devastating act of sexual violence with far-reaching physical and
psychological consequences
Gastric cancer risk factors - ANSWER - The presence of H.pylori in the stomach
increases the risk of gastric cancer
-H. Pylori cause peptic ulcer disease
Albuterol adverse effects - ANSWER - It's a medication for asthma that can cause
-arrhythmia
-tachycardia
-chest pain
-hives, skin rash
-bronchospasm, dyspnea
Nursing intervention For Venous stasis - ANSWER - -application of compression
stockings with a pressure gradient of 30-40 mm Hg at the ankle
-select a wound dressing which keeps the wound bed moist
-a diet plan with foods high in protein, iron, vitamin A, C, and Zinc
3
, -apply short-stretch elastic bandages as an option for compression therapy
Nursing goal for venous insufficiency - ANSWER - -reduced stasis
-no signs of infection
-intact skin integrity
Venous insufficiency - ANSWER - Is caused by venous hypertension,
inflammatory changes, and obstruction of venous valves (venous ulcers)
-post thrombotic syndrome (PTS)
PTS (post-thrombotic syndrome) - ANSWER - Is a complication of venous
thromboembolism (VTE) which can progress to chronic venous insufficiency
(VTI).
peripheral arterial disease (PAD) - ANSWER - -affected limbs rarely develops
edema
-skin appearance is shiny, taut, and thin with reduced or absent pedal pulse
-cool skin
-abnormal ankle brachial index
Chronic Venous Insufficiency (CVI) - ANSWER - -skin becomes thickened,
hardened and pedal pulses are difficult to palpate due to edema
-skin is warm, and pruritus often present
deep vein thrombosis (DVT) - ANSWER - -nonspecific symptoms or unilateral
limb edema
-veins may appear as a palpable cord
4
EXAM [450] QUESTIONS AND CORRECT ANSWERS WITH
RATIONALES| ALREADY GRADED A+
Z-Track method - ANSWER - It reduces irritation to the subcutaneous and skin
tissues
Milieu therapy - ANSWER - Provide a consistent set of activities and
responsibilities for each client
Alzheimer's disease (AD) - ANSWER - A progressive disease that destroys the
brain's neurons, gradually impairing memory, thinking, language, and other
cognitive functions, resulting in the complete inability to care for oneself; the most
common cause of dementia.
-Temperature extremes or excessive noise can agitate the client and trigger
behavior changes.
Which client can assign to the New nurse - ANSWER - A client with a chronic
condition who is awaiting discharge
Amikacin - ANSWER - -An aminoglycoside antibiotic
-can cause nausea and diarrhea
-can cause nephrotoxicity and ototoxicity
-contraindicated with renal damage
-can potentiate the action of warfarin
Panic attacks - ANSWER - -the client is pacing, hyperventilating, and unable to
follow instructions
1
,-stay with the client
Vaccine guidelines for a 2 months old - ANSWER - -rotavirus
-diphtheria, tetanus, and pertussis
-Haemophilus influenzae (HIB)
Poliovirus
-streptococcus pneumonia
Hemolytic reactions - ANSWER - When happened
-the infusion should be stopped if hematuria occurs
-stopping it immediately
-follow facility protocol
Alcohol withdrawal symptoms - ANSWER - Hyperalertness, easily startled,
anorexia, tremors, increased pulse, and anxiety.
food pocketing - ANSWER - A client who pocketed food has a high priority
because the client is at risk for aspiration
Client under legal guardianship - ANSWER - Client under legal guardianship have
lost mental competence to make medical decisions for themselves
Rh factor incompatibility - ANSWER - Required attention but only if:
-mother is Rh-negative and baby Rh-Positive
ABO incompatibility - ANSWER - Mother's blood type is O
2
,Infant's blood type is A, B, or AB
Dissociative disorders - ANSWER - The client said " I don't know who I am or
where I live "
-sudden or gradual disruption in the integration function of identity, memory, or
consciousness
A client said "I was raped last night " - ANSWER - -reassure the client of being in
a place
Because rape is a devastating act of sexual violence with far-reaching physical and
psychological consequences
Gastric cancer risk factors - ANSWER - The presence of H.pylori in the stomach
increases the risk of gastric cancer
-H. Pylori cause peptic ulcer disease
Albuterol adverse effects - ANSWER - It's a medication for asthma that can cause
-arrhythmia
-tachycardia
-chest pain
-hives, skin rash
-bronchospasm, dyspnea
Nursing intervention For Venous stasis - ANSWER - -application of compression
stockings with a pressure gradient of 30-40 mm Hg at the ankle
-select a wound dressing which keeps the wound bed moist
-a diet plan with foods high in protein, iron, vitamin A, C, and Zinc
3
, -apply short-stretch elastic bandages as an option for compression therapy
Nursing goal for venous insufficiency - ANSWER - -reduced stasis
-no signs of infection
-intact skin integrity
Venous insufficiency - ANSWER - Is caused by venous hypertension,
inflammatory changes, and obstruction of venous valves (venous ulcers)
-post thrombotic syndrome (PTS)
PTS (post-thrombotic syndrome) - ANSWER - Is a complication of venous
thromboembolism (VTE) which can progress to chronic venous insufficiency
(VTI).
peripheral arterial disease (PAD) - ANSWER - -affected limbs rarely develops
edema
-skin appearance is shiny, taut, and thin with reduced or absent pedal pulse
-cool skin
-abnormal ankle brachial index
Chronic Venous Insufficiency (CVI) - ANSWER - -skin becomes thickened,
hardened and pedal pulses are difficult to palpate due to edema
-skin is warm, and pruritus often present
deep vein thrombosis (DVT) - ANSWER - -nonspecific symptoms or unilateral
limb edema
-veins may appear as a palpable cord
4
