NCLEX-RN Exam 1 NGN/ NCLEX RN NGN Latest New
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The nurse witnesses the collapse of a child while outdoors. The child is not
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breathing and has a pulse of 50/min. The nurse calls emergency services and
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initiates rescue breathing. After 2 minutes of rescue breaths, the child is still
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not breathing and is pale with a pulse of 30/min.
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What is the nurse's next action?
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1. Initiate chest compressions
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Rescue breathing is performed at a rate of 1 breath every 2-3 seconds. If the
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pulse remains
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<60/min and there are signs of poor perfusion (skin pallor), the nurse
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should initiate chest compressions and reassess the pulse every 2 minutes
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The charger nurse is responsible for making room assignments multiple
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clients. Which pari of client assignments to a shared room is appropriate?
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3. Client who had a bowel resection 1 day ago and client with asthma
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,exacerbation.
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When making room assignments, it is important to remember that a client
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with an active or suspected infection should not be paired with a client who
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has a fresh surgical wound or is immunocompromised. A client having an
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asthma exacerbation does not have an infection and is not at risk for
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spreading infection to a client who had a recent bowel resection surgery.
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The clinic nurse is assessing a client who is being treated for depression and
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suicidal ideation. Which client statement best indicates that the client is not
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currently at risk for suicide?
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2. "I plan to attend my grandchild's graduation next month"
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Clients receiving treatment for depression and suicidal ideation must be
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mcarefully monitored for indications of increasing suicidal intent. During a client
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minterview, the nurse should assess: m m m m
- Access to psychiatric medications
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- Availability of help during a crisis (counselor, family)
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- Future goals and plansm m m
- Home and environment risks
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,- Overall affect and level of energy
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- Possible access to weapons m m m
Clients who articulate long-term personal goals and family milestones are less
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likely to attemptdeath by suicide
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The nurse is caring for a client who had an anterior wall myocardial
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infarction 2 days ago. The telemetry technician notifies the nurse at 8:30
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AM that the client is in ventricular trigeminy. What is the nurse's priority
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intervention?
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1. Administer potassium supplement
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In ventricular trigeminy, premature ventricular contractions (PVCs) occur every
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mthird heartbeat. Myocardial injury (eg, myocardial infarction) predisposes the
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mclient to ectopy (eg, PVCs), which increases the client's risk for lethal
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mdysrhythmias (eg, ventricular tachycardia). PVCs are caused and/or exacerbated
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mby hypoxia, electrolyte imbalances, emotional stress, stimulants, fever, and
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exercise.
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This client's morning laboratory results show hypokalemia (potassium <3.5
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mEq/L [3.5 mmol/L]); therefore, the priority is treatment of the underlying
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cause of the ectopy by administering the prescribed potassium replacement
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(Option 1). Health care providers (HCPs) often prescribe electrolyte
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replacement algorithms to clients at risk for electrolyte imbalances (eg,
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myocardial injury, receiving diuretics) unless a contraindication exists (eg, serum
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creatinine
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>1.5 mg/dL [133 µmol/L], anuric, weight <99.2 lb [45 kg]).
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The nurse cares for a client with a terminal disease who created a do not
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attempt resuscitation (DNAR) directive. The client stops breathing and loses
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their pulse. The client's adult child states, "Please, do whatever you can to
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save them!" Which intervention is appropriate?
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3. Explain the client's resuscitation directive to the client's child
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Clients can create a do not attempt resuscitation (DNAR) directive instructing
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, that CPR and other life-saving measures be withheld. With an advance
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directive in place, the client's wishes should be followed, even if they conflict
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with the wishes of loved ones
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The nurse in the cardiac intensive care unit receives report on 4 clients.
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Which client should the nurse assess first?
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2. Client who underwent coronary artery stent placement via femoral
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approach 3 hours ago and is reporting severe back pain
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A client who undergoes percutaneous coronary intervention (PCI) and
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intracoronary stent placement using the femoral approach is at increased risk
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for retroperitoneal hemorrhage. Administration of antithrombotic drugs before,
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during, and after PCI can exacerbate potentially
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