NCLEX EXAM QUESTIONS
enoxaparin indications ANS: DVT prophylaxis
what should nurse have ready with Blakemore tube and why ANS: scissors
if balloon becomes displaced can compress trachea and cause respiratory arrest
For newborns, where do you check pulse ANS: Apical pulse
Where is apical pulse located for adults ANS: 5th ICS, midclavicular line
When is CRIES pain scale used and what does it stand for ANS: Neonatal intensive care unit, infants who
are less than 38 weeks gestation
Crying
Requires oxygen
Increased vital signs
Expression
Sleeplessness
When is FLACC scale used ANS: 2 months to 7 years of age who are unable to communicate
Face
Legs
Activity
,Cry
Consolability
What is normal ICP ANS: 5-15 mmHg
What is normal pulmonary artery pressure ANS: 8-20 mmHg
What is the term for high pulmonary artery pressure and what does it impact ANS: Pulmonary
hypertension
affects right side of heart and arteries going to lungs
How can you measure pulmonary artery pressure ANS: doppler echo
Describe MRI ANS: uses magnetic fields and radio waves to determine anatomy
lasts 15-60 mins
may show soft tissue/organ changes
great to see brain, spinal cord, and nerves
may or may not use contrast
What should a client/nurse do before an MRI ANS: remove metals (watches, jewelry)
,assess for claustrophobia
assess if patient has pacemaker
- old MRIs may deactivate them
- some newer ones are safe
Contraindications for MRI ANS: agitation
metal implants
old tattoos (lead)
Describe CT scan ANS: uses x-rays to create 3-D image
donut shaped scanner
may or may not use contrast (contrast good for tumor identification)
patient must remain still
5-10 min
*best way to see bones
What should be checked before giving contrast ANS: renal function
, What should be done before and after getting contrast ANS: increase fluids post contrast
hold metformin 24 hours before and 48 hours after
monitor urine output closely after CT
What should a client do if they are going to get an ultrasound on their digestive system ANS: no fluids or
food
What should a client do if they are going to get an ultrasound of their pelvis or fetus ANS: have a full
bladder
Order of lab collection with central line ANS: 1. gather supplies
2. hand hygiene
3. rub alcohol swab on lumen
4. flush central line with 10 mL NS
5. draw 10 mL blood and discard
6. draw 10 mL blood and put into tubes
7. flush with 10-20 mL NS
enoxaparin indications ANS: DVT prophylaxis
what should nurse have ready with Blakemore tube and why ANS: scissors
if balloon becomes displaced can compress trachea and cause respiratory arrest
For newborns, where do you check pulse ANS: Apical pulse
Where is apical pulse located for adults ANS: 5th ICS, midclavicular line
When is CRIES pain scale used and what does it stand for ANS: Neonatal intensive care unit, infants who
are less than 38 weeks gestation
Crying
Requires oxygen
Increased vital signs
Expression
Sleeplessness
When is FLACC scale used ANS: 2 months to 7 years of age who are unable to communicate
Face
Legs
Activity
,Cry
Consolability
What is normal ICP ANS: 5-15 mmHg
What is normal pulmonary artery pressure ANS: 8-20 mmHg
What is the term for high pulmonary artery pressure and what does it impact ANS: Pulmonary
hypertension
affects right side of heart and arteries going to lungs
How can you measure pulmonary artery pressure ANS: doppler echo
Describe MRI ANS: uses magnetic fields and radio waves to determine anatomy
lasts 15-60 mins
may show soft tissue/organ changes
great to see brain, spinal cord, and nerves
may or may not use contrast
What should a client/nurse do before an MRI ANS: remove metals (watches, jewelry)
,assess for claustrophobia
assess if patient has pacemaker
- old MRIs may deactivate them
- some newer ones are safe
Contraindications for MRI ANS: agitation
metal implants
old tattoos (lead)
Describe CT scan ANS: uses x-rays to create 3-D image
donut shaped scanner
may or may not use contrast (contrast good for tumor identification)
patient must remain still
5-10 min
*best way to see bones
What should be checked before giving contrast ANS: renal function
, What should be done before and after getting contrast ANS: increase fluids post contrast
hold metformin 24 hours before and 48 hours after
monitor urine output closely after CT
What should a client do if they are going to get an ultrasound on their digestive system ANS: no fluids or
food
What should a client do if they are going to get an ultrasound of their pelvis or fetus ANS: have a full
bladder
Order of lab collection with central line ANS: 1. gather supplies
2. hand hygiene
3. rub alcohol swab on lumen
4. flush central line with 10 mL NS
5. draw 10 mL blood and discard
6. draw 10 mL blood and put into tubes
7. flush with 10-20 mL NS
