NCLEX NGN 202 ACTUAL EXAM ALL 180
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (ALREADY
GRADED A+)
A nurse is assigned to care for a client with chronic renal failure
| | | | | | | | | | | |
who is undergoing hemodialysis through an internal AV fistula in
| | | | | | | | | |
the RA. Which intervention should the nurse implement in caring
| | | | | | | | | |
for the client? SATA
| | | |
a. Assessing |the |radial |pulse |in |the |right |extremity
b. Using |the |LA |ti |take |BP |readings
c. Drawing |pre-dialysis |blood |specimens |from |the |LA
d. Assessing |the |area |over |the |AV |fistula |for |a |bruit |and |three |each |shift
e. Placing |a |pressure |dressing |over |the |site |after |each |dialysis |treatment
f. Administering |IV |fluids |through |the |venous |site |of |the |AV |fistula |as |needed |- |answer-A, |B, |C, |D
A |nurse |is |evaluating |outcomes |for |a |client |with |Guillain-Barre |syndrome. |Which |outcome |does |the
|nurse |recognize |as |optimal |respiratory |outcomes |for |the |client?
a. Normal |deep |tendon |reflexes
b. Improved |skeletal |muscle |tone
c. Absences |of |paresthesias |in |the |lower |extremities
d. Clear |sound |in |the |lower |lung |fields |bilaterally
e. pO2 |of |85 |mmHg |and |pCO2 |of |40 |mmHg |- |answer-D, |E
A |nurse |of |the |telemetry |unit |is |caring |for |a |client |who |has |had |a |MI |and |is |now |attached |to |a |cardiac
|monitor. |The |nurse |is |monitoring |the |client's |cardiac |rhythm |and |nots |ventricular |fibrillation. |Which
|nursing |intervention |should |the |nurse |take |first?
a. Calling |the |rapid |response |team
b. Preparing |the |client |for |cardioversion
c. Asking |the |client |to |bear |down |and |cough
d. Preparing |to |administer |diltiazem |- |answer-A
,The |pattern |of |ventricular |fibrillation |is |identified |and |can |be |a |result |after |a |patient |with |an |MI. |VF
|makes |the |patient |feel |faint, |then |loses |consciousness |and |becomes |pulseless |and |apneic |(BP |and
|heart
, sounds |absent). |Treatment |is |to |terminate |VF |and |covert |it |into |a |rhythm |via |defibrillation-> |call |a
|rapid |and |initiate |CPR. |Cardioversion |is |used |for |ventricular |or |supraventricular |tachydysrhythmias.
A |nurse |developing |a |plan |of |care |for |a |client |with |a |spinal |cord |injury |includes |measures |to |prevent
|autonomic |dysreflexia |(hyperreflexia). |Which |intervention |does |the |nurse |incorporate |into |the |plan
|to |prevent |this |complication?
a. Keeping |the |fan |running |in |the |client's |room
b. Keeping |the |linens |wrinkle |free |under |the |client
c. Limiting |bladder |catheterization |to |once |every |12 |hours
d. Avoiding |the |administration |of |enemas |and |rectal |suppositories |- |answer-B
The |most |frequent |cause |of |autonomic |dysreflexias |are |a |distended |bladder |and |impacted |feces.
|Other |causes |include |stimulation |of |the |skin |by |tactile, |thermal, |or |painful |stimuli. |The |nurse
|renders |care |in |such |a |way |as |to |minimize |these |risks.
A |nurse |provides |home |care |instructions |to |a |client |who |has |been |fitted |with |a |halo |device |to |treat |a
|cervical |fracture. |Which |statement |by |the |client |indicates |the |need |for |further |teaching?
a. I |need |to |get |more |fluids |and |fiber |into |my |diet
b. I |should |cut |my |food |into |small |pieces |before |I |eat
c. I |need |to |put |powder |under |the |vest |twice |a |day |to |prevent |sweating
d. I |have |to |check |the |pin |sites |everyday |and |watch |for |signs |of |infection |-
answer-C |Cleanse |the |skin |under |the |wool |liner |each |day |to |prevent |rashes |and
|
soars.
|
A |nurse |is |caring |for |a |client |with |increased |intracranial |pressure. |In |which |position |should |the |nurse
|maintain |the |client?
a. Supine |with |the |head |extended
b. Side |lying |with |the |neck |flexed
c. Supine |with |the |head |turned |to |the |side
d. Head |midline |and |elevated |30-45 |degrees |- |answer-D
Proper |positioning |promotes |venous |drainage |from |the |cranium |to |minimize |ICP.
A |client |with |a |basilar |skull |fracture |has |clear |fluid |leaking |from |the |ears. |The |nurse |should |take
|which |action |first?
QUESTIONS AND CORRECT DETAILED
ANSWERS WITH RATIONALES (ALREADY
GRADED A+)
A nurse is assigned to care for a client with chronic renal failure
| | | | | | | | | | | |
who is undergoing hemodialysis through an internal AV fistula in
| | | | | | | | | |
the RA. Which intervention should the nurse implement in caring
| | | | | | | | | |
for the client? SATA
| | | |
a. Assessing |the |radial |pulse |in |the |right |extremity
b. Using |the |LA |ti |take |BP |readings
c. Drawing |pre-dialysis |blood |specimens |from |the |LA
d. Assessing |the |area |over |the |AV |fistula |for |a |bruit |and |three |each |shift
e. Placing |a |pressure |dressing |over |the |site |after |each |dialysis |treatment
f. Administering |IV |fluids |through |the |venous |site |of |the |AV |fistula |as |needed |- |answer-A, |B, |C, |D
A |nurse |is |evaluating |outcomes |for |a |client |with |Guillain-Barre |syndrome. |Which |outcome |does |the
|nurse |recognize |as |optimal |respiratory |outcomes |for |the |client?
a. Normal |deep |tendon |reflexes
b. Improved |skeletal |muscle |tone
c. Absences |of |paresthesias |in |the |lower |extremities
d. Clear |sound |in |the |lower |lung |fields |bilaterally
e. pO2 |of |85 |mmHg |and |pCO2 |of |40 |mmHg |- |answer-D, |E
A |nurse |of |the |telemetry |unit |is |caring |for |a |client |who |has |had |a |MI |and |is |now |attached |to |a |cardiac
|monitor. |The |nurse |is |monitoring |the |client's |cardiac |rhythm |and |nots |ventricular |fibrillation. |Which
|nursing |intervention |should |the |nurse |take |first?
a. Calling |the |rapid |response |team
b. Preparing |the |client |for |cardioversion
c. Asking |the |client |to |bear |down |and |cough
d. Preparing |to |administer |diltiazem |- |answer-A
,The |pattern |of |ventricular |fibrillation |is |identified |and |can |be |a |result |after |a |patient |with |an |MI. |VF
|makes |the |patient |feel |faint, |then |loses |consciousness |and |becomes |pulseless |and |apneic |(BP |and
|heart
, sounds |absent). |Treatment |is |to |terminate |VF |and |covert |it |into |a |rhythm |via |defibrillation-> |call |a
|rapid |and |initiate |CPR. |Cardioversion |is |used |for |ventricular |or |supraventricular |tachydysrhythmias.
A |nurse |developing |a |plan |of |care |for |a |client |with |a |spinal |cord |injury |includes |measures |to |prevent
|autonomic |dysreflexia |(hyperreflexia). |Which |intervention |does |the |nurse |incorporate |into |the |plan
|to |prevent |this |complication?
a. Keeping |the |fan |running |in |the |client's |room
b. Keeping |the |linens |wrinkle |free |under |the |client
c. Limiting |bladder |catheterization |to |once |every |12 |hours
d. Avoiding |the |administration |of |enemas |and |rectal |suppositories |- |answer-B
The |most |frequent |cause |of |autonomic |dysreflexias |are |a |distended |bladder |and |impacted |feces.
|Other |causes |include |stimulation |of |the |skin |by |tactile, |thermal, |or |painful |stimuli. |The |nurse
|renders |care |in |such |a |way |as |to |minimize |these |risks.
A |nurse |provides |home |care |instructions |to |a |client |who |has |been |fitted |with |a |halo |device |to |treat |a
|cervical |fracture. |Which |statement |by |the |client |indicates |the |need |for |further |teaching?
a. I |need |to |get |more |fluids |and |fiber |into |my |diet
b. I |should |cut |my |food |into |small |pieces |before |I |eat
c. I |need |to |put |powder |under |the |vest |twice |a |day |to |prevent |sweating
d. I |have |to |check |the |pin |sites |everyday |and |watch |for |signs |of |infection |-
answer-C |Cleanse |the |skin |under |the |wool |liner |each |day |to |prevent |rashes |and
|
soars.
|
A |nurse |is |caring |for |a |client |with |increased |intracranial |pressure. |In |which |position |should |the |nurse
|maintain |the |client?
a. Supine |with |the |head |extended
b. Side |lying |with |the |neck |flexed
c. Supine |with |the |head |turned |to |the |side
d. Head |midline |and |elevated |30-45 |degrees |- |answer-D
Proper |positioning |promotes |venous |drainage |from |the |cranium |to |minimize |ICP.
A |client |with |a |basilar |skull |fracture |has |clear |fluid |leaking |from |the |ears. |The |nurse |should |take
|which |action |first?
