NCLEX-RN Test 1 NGN
Study online at https://quizlet.com/_edx254
1. The nurse wit- 1. Initiate chest compressions
nesses the col-
lapse of a child Rescue breathing is performed at a rate of 1 breath every 2-3 seconds. If the pulse
while outdoors. remains <60/min and there are signs of poor perfusion (skin pallor), the nurse
The child is not should initiate chest compressions and reassess the pulse every 2 minutes
breathing and
has a pulse
of 50/min. The
nurse calls emer-
gency services
and initiates res-
cue breathing.
After 2 min-
utes of rescue
breaths, the child
is still not breath-
ing and is pale
with a pulse of
30/min. What is
the nurse's next
action?
2. The charger 3. Client who had a bowel resection 1 day ago and client with asthma exacerba-
nurse is respon- tion.
sible for mak-
ing room as- When making room assignments, it is important to remember that a client with
signments multi- an active or suspected infection should not be paired with a client who has
ple clients. Which a fresh surgical wound or is immunocompromised. A client having an asthma
pari of client as- exacerbation does not have an infection and is not at risk for spreading infection
signments to a to a client who had a recent bowel resection surgery.
shared room is
appropriate?
, NCLEX-RN Test 1 NGN
Study online at https://quizlet.com/_edx254
3. The clinic nurse 2. "I plan to attend my grandchild's graduation next month"
is assessing a
client who is be- Clients receiving treatment for depression and suicidal ideation must be carefully
ing treated for monitored for indications of increasing suicidal intent. During a client interview,
depression and the nurse should assess:
suicidal ideation. - Access to psychiatric medications
Which client - Availability of help during a crisis (counselor, family)
statement best - Future goals and plans
indicates that the - Home and environment risks
client is not cur- - Overall affect and level of energy
rently at risk for - Possible access to weapons
suicide?
Clients who articulate long-term personal goals and family milestones are less
likely to attempt death by suicide
4. The nurse is car- 1. Administer potassium supplement
ing for a client
who had an ante- In ventricular trigeminy, premature ventricular contractions (PVCs) occur every
rior wall myocar- third heartbeat. Myocardial injury (eg, myocardial infarction) predisposes the
dial infarction 2 client to ectopy (eg, PVCs), which increases the client's risk for lethal dysrhythmias
days ago. The (eg, ventricular tachycardia). PVCs are caused and/or exacerbated by hypoxia,
telemetry techni- electrolyte imbalances, emotional stress, stimulants, fever, and exercise.
cian notifies the
This client's morning laboratory results show hypokalemia (potassium <3.5 mEq/L
nurse at 8:30 AM
[3.5 mmol/L]); therefore, the priority is treatment of the underlying cause of
that the client
the ectopy by administering the prescribed potassium replacement (Option 1).
is in ventricular
Health care providers (HCPs) often prescribe electrolyte replacement algorithms
trigeminy. What
to clients at risk for electrolyte imbalances (eg, myocardial injury, receiving di-
is the nurse's
uretics) unless a contraindication exists (eg, serum creatinine >1.5 mg/dL [133
priority interven-
µmol/L], anuric, weight <99.2 lb [45 kg]).
tion?
5.
, NCLEX-RN Test 1 NGN
Study online at https://quizlet.com/_edx254
The nurse cares 3. Explain the client's resuscitation directive to the client's child
for a client with
a terminal dis- Clients can create a do not attempt resuscitation (DNAR) directive instructing that
ease who creat- CPR and other life-saving measures be withheld. With an advance directive in
ed a do not at- place, the client's wishes should be followed, even if they conflict with the wishes
tempt resuscita- of loved ones
tion (DNAR) di-
rective. The client
stops breath-
ing and los-
es their pulse.
The client's adult
child states,
"Please, do what-
ever you can
to save them!"
Which interven-
tion is appropri-
ate?
6. The nurse in 2. Client who underwent coronary artery stent placement via femoral approach 3
the cardiac inten- hours ago and is reporting severe back pain
sive care unit re-
ceives report on A client who undergoes percutaneous coronary intervention (PCI) and intracoro-
4 clients. Which nary stent placement using the femoral approach is at increased risk for retroperi-
client should the toneal hemorrhage. Administration of antithrombotic drugs before, during, and
nurse assess after PCI can exacerbate potentially life-threatening bleeding from the femoral
first? artery.
Hypotension, back pain, flank ecchymosis (eg, Grey Turner sign), hematoma
formation, and diminished distal pulses can be early signs of bleeding into the
, NCLEX-RN Test 1 NGN
Study online at https://quizlet.com/_edx254
retroperitoneal space and require immediate intervention (eg, notify health care
provider, serial complete blood count, CT scan of the abdomen)
7. The nurse is re- 4. Peripheral arterial disease
viewing the med-
ical history of a Bone healing depends on multiple factors, including nutrition, adequate circula-
client who has tion, and age. A client with peripheral arterial disease has decreased perfusion to
sustained a right the extremities due to atherosclerotic changes in the arteries. Without adequate
tibia/fibula frac- perfusion, the bone is not supplied with the oxygen and nutrients required for
ture from a fall. healing
The nurse identi-
fies which finding
as most likely to
hinder healing?
8. Based on the WRONG
nursing assess-
ment progress 2. Stage 2: Stage 2 pressure injuries have partial-thickness skin loss (abrasion,
notes, what is blister, or shallow crater). The skin blisters or forms an open sore, and the area
the correct stag- around the sore may be red and irritated. (shallow, open ulcer, red-pink wound
ing of the client's with no sloughing and possible intact or ruptured blister)
pressure injury?
Stage 1: Intact skin with nonblanchable redness
Click on the ex-
Stage 2: Partial-thickness skin loss (abrasion, blister, or shallow crater) involving
hibit button for
the dermis or epidermis; the wound bed is red or pink and may be shiny or dry
additional infor-
Stage 3: Full-thickness skin loss; subcutaneous fat is visible but not tendon,
mation.
muscle, or bone; tunneling may be present
Stage 4: Full-thickness skin loss with visible tendon, muscle, or bone; slough or
eschar (scabbing, dead tissue) may be present; undermining and tunneling may
be present
Pressure injuries are described as "unstageable" if the base is covered by necrotic
tissue or eschar
Study online at https://quizlet.com/_edx254
1. The nurse wit- 1. Initiate chest compressions
nesses the col-
lapse of a child Rescue breathing is performed at a rate of 1 breath every 2-3 seconds. If the pulse
while outdoors. remains <60/min and there are signs of poor perfusion (skin pallor), the nurse
The child is not should initiate chest compressions and reassess the pulse every 2 minutes
breathing and
has a pulse
of 50/min. The
nurse calls emer-
gency services
and initiates res-
cue breathing.
After 2 min-
utes of rescue
breaths, the child
is still not breath-
ing and is pale
with a pulse of
30/min. What is
the nurse's next
action?
2. The charger 3. Client who had a bowel resection 1 day ago and client with asthma exacerba-
nurse is respon- tion.
sible for mak-
ing room as- When making room assignments, it is important to remember that a client with
signments multi- an active or suspected infection should not be paired with a client who has
ple clients. Which a fresh surgical wound or is immunocompromised. A client having an asthma
pari of client as- exacerbation does not have an infection and is not at risk for spreading infection
signments to a to a client who had a recent bowel resection surgery.
shared room is
appropriate?
, NCLEX-RN Test 1 NGN
Study online at https://quizlet.com/_edx254
3. The clinic nurse 2. "I plan to attend my grandchild's graduation next month"
is assessing a
client who is be- Clients receiving treatment for depression and suicidal ideation must be carefully
ing treated for monitored for indications of increasing suicidal intent. During a client interview,
depression and the nurse should assess:
suicidal ideation. - Access to psychiatric medications
Which client - Availability of help during a crisis (counselor, family)
statement best - Future goals and plans
indicates that the - Home and environment risks
client is not cur- - Overall affect and level of energy
rently at risk for - Possible access to weapons
suicide?
Clients who articulate long-term personal goals and family milestones are less
likely to attempt death by suicide
4. The nurse is car- 1. Administer potassium supplement
ing for a client
who had an ante- In ventricular trigeminy, premature ventricular contractions (PVCs) occur every
rior wall myocar- third heartbeat. Myocardial injury (eg, myocardial infarction) predisposes the
dial infarction 2 client to ectopy (eg, PVCs), which increases the client's risk for lethal dysrhythmias
days ago. The (eg, ventricular tachycardia). PVCs are caused and/or exacerbated by hypoxia,
telemetry techni- electrolyte imbalances, emotional stress, stimulants, fever, and exercise.
cian notifies the
This client's morning laboratory results show hypokalemia (potassium <3.5 mEq/L
nurse at 8:30 AM
[3.5 mmol/L]); therefore, the priority is treatment of the underlying cause of
that the client
the ectopy by administering the prescribed potassium replacement (Option 1).
is in ventricular
Health care providers (HCPs) often prescribe electrolyte replacement algorithms
trigeminy. What
to clients at risk for electrolyte imbalances (eg, myocardial injury, receiving di-
is the nurse's
uretics) unless a contraindication exists (eg, serum creatinine >1.5 mg/dL [133
priority interven-
µmol/L], anuric, weight <99.2 lb [45 kg]).
tion?
5.
, NCLEX-RN Test 1 NGN
Study online at https://quizlet.com/_edx254
The nurse cares 3. Explain the client's resuscitation directive to the client's child
for a client with
a terminal dis- Clients can create a do not attempt resuscitation (DNAR) directive instructing that
ease who creat- CPR and other life-saving measures be withheld. With an advance directive in
ed a do not at- place, the client's wishes should be followed, even if they conflict with the wishes
tempt resuscita- of loved ones
tion (DNAR) di-
rective. The client
stops breath-
ing and los-
es their pulse.
The client's adult
child states,
"Please, do what-
ever you can
to save them!"
Which interven-
tion is appropri-
ate?
6. The nurse in 2. Client who underwent coronary artery stent placement via femoral approach 3
the cardiac inten- hours ago and is reporting severe back pain
sive care unit re-
ceives report on A client who undergoes percutaneous coronary intervention (PCI) and intracoro-
4 clients. Which nary stent placement using the femoral approach is at increased risk for retroperi-
client should the toneal hemorrhage. Administration of antithrombotic drugs before, during, and
nurse assess after PCI can exacerbate potentially life-threatening bleeding from the femoral
first? artery.
Hypotension, back pain, flank ecchymosis (eg, Grey Turner sign), hematoma
formation, and diminished distal pulses can be early signs of bleeding into the
, NCLEX-RN Test 1 NGN
Study online at https://quizlet.com/_edx254
retroperitoneal space and require immediate intervention (eg, notify health care
provider, serial complete blood count, CT scan of the abdomen)
7. The nurse is re- 4. Peripheral arterial disease
viewing the med-
ical history of a Bone healing depends on multiple factors, including nutrition, adequate circula-
client who has tion, and age. A client with peripheral arterial disease has decreased perfusion to
sustained a right the extremities due to atherosclerotic changes in the arteries. Without adequate
tibia/fibula frac- perfusion, the bone is not supplied with the oxygen and nutrients required for
ture from a fall. healing
The nurse identi-
fies which finding
as most likely to
hinder healing?
8. Based on the WRONG
nursing assess-
ment progress 2. Stage 2: Stage 2 pressure injuries have partial-thickness skin loss (abrasion,
notes, what is blister, or shallow crater). The skin blisters or forms an open sore, and the area
the correct stag- around the sore may be red and irritated. (shallow, open ulcer, red-pink wound
ing of the client's with no sloughing and possible intact or ruptured blister)
pressure injury?
Stage 1: Intact skin with nonblanchable redness
Click on the ex-
Stage 2: Partial-thickness skin loss (abrasion, blister, or shallow crater) involving
hibit button for
the dermis or epidermis; the wound bed is red or pink and may be shiny or dry
additional infor-
Stage 3: Full-thickness skin loss; subcutaneous fat is visible but not tendon,
mation.
muscle, or bone; tunneling may be present
Stage 4: Full-thickness skin loss with visible tendon, muscle, or bone; slough or
eschar (scabbing, dead tissue) may be present; undermining and tunneling may
be present
Pressure injuries are described as "unstageable" if the base is covered by necrotic
tissue or eschar
