NCLEX-RN exam with 100% correct answers 2024., Exams of Nursing

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answers 2024

RBC - ANSWER-4.2-6.

WBC - ANSWER-4,500-11,

Platelets - ANSWER-150,000-450, Hematocrit - ANSWER-35-52% Hemoglobin - ANSWER-12- Normal Bleeding Time - ANSWER-1.5-9.5 minutes PTT - ANSWER-20-39 seconds PT - ANSWER-9.5-12 seconds INR - ANSWER-1.0 normal 2-3 seconds for a.fib treatment 2.5-3.5 seconds for prosthetic heart valves ESR - ANSWER-<30 mm/hr >50 years old <25 mm/hr if <50 years old (time that erythrocytes settle in well mixed venous blood)

answers 2024

Blood Sugar - ANSWER-60- Cholesterol - ANSWER-150- LDL - ANSWER-<160 (<100 if CAD) HDL - ANSWER-35- Triglycerides - ANSWER-100- BUN - ANSWER-10-20 g/dL (high=kidney failure) Cr - ANSWER-0.4-1.4 (high=kidney failure) Urine Specific Gravity - ANSWER-1.005-1. Alkaline Phosphatase - ANSWER-50-120u/L (increased=liver damage) Creatine Kinase - ANSWER-MM bands present= skeletal muscle damage MB bands present= cardiac muscle damage elevated= MI (>336 Males, >176 Females) Albumin - ANSWER-3.5-5.

answers 2024

ALT and AST - ANSWER-10-40 (high=liver damage/failure) Bilirubin - ANSWER-<5 in newborns 0.3-1 in adults Therapeutic Digoxin Level - ANSWER-0.5- Sodium - ANSWER-135- Potassium - ANSWER-3.5- Calcium - ANSWER-8.6-10. Magnesium - ANSWER-1.3-2. Cranial Nerves - ANSWER-1- Olfactory (smell) 2-Optic (vision) 3- Oculomotor (pupil constriction, raising eyelid) 4- Throclear (down and inward eye movement) 5- Trigminal (jaw movement; face/neck sensation) 6- Abducens (lateral eye movement) 7-Facial (movement/taste) 8- Acoustic (hearing/balance) 9-Glossopharyngeal (pharyngeal/movement, taste)

answers 2024

10-Vagus (swallow/speaking) 11- Spinal Accessory (flex/roatation of the head and shoulder shrugging) 12- Hypoglossal (tongue movement) What do you do for a transfusion reaction? - ANSWER-Stop, Restart NS, Save blood/tubing and return to blood bank, Draw blood sample, Urine sample, Monitor for hematuria Hemolytic Reaction - ANSWER-From incompatibility--> have N/V, chills, lower back pain, hypotension, increased HR Isotonic Fluids - ANSWER-Same concentration as body fluids (NS,LR,D5W) Hypotonic Fluids - ANSWER-Less concentration than body fluids- pulls water into the cell= cell bursts (1/2NS) given with dehydration Hypertonic Fluids - ANSWER-More concentration than body fluids- pulls water out of the cell= cell shrivels (10-15% D, NaBicarb 5%) given for hyponatremia IV Insertion - ANSWER-Using non dominant hand, place tourniquet 4-6" above, warm area/hand over bed/make a fist to dilate vein Clean with alcohol inside to outside then with iodine Insert at 10-30 degree angle and lessen, once you see blood lower 1/4" and remove tourniquet, remove needle and advance catheter Secure, tubing, infuse Rapid Acting Insulin - ANSWER-O=10-30 min P=0.5-3 hr D= 3-6 hr

answers 2024

Lispro, Aspart, Glusine Short Acting Insulin - ANSWER-O=30-60 min P= 1-5 hr D= 6-10 hr Regular Intermediate Insulin - ANSWER-O= 1-2 hr P= 6-12 hr D= 16 hr NPH Long Acting Insulin - ANSWER-O= 3-4 hr P= cont D= 24hr Meds to take at night - ANSWER-Stating H2Antagonists Antisecretory Tricyclic Alpha Adrenergic Blockers Meds that interact with grapefruit - ANSWER-Can increase serum drug level- CCB, Statings, Caffeine, SSRIs, Dextromorphan, Sirolimus, Carbamazepine, Buspirone, Midazolam, Sildenafil, Praziquantel, Tacrolimus Stoma Care - ANSWER-Will function 3-6 days post op~ want a low residue diet 6-8wks post op! Swelling normal in first few days post op pouch opening 1/8 inch larger than stoma, skin barrier under all tapes and to protect skin surrounding stoma, cleanse gently/pat dry, use stoma adhesive/hold pouch for 30 sec when setting and change if seal breaks or if 1/ full

answers 2024

Bleeding Precautions - ANSWER-Electric Razor Soft Toothbrush Pressure post venipuncture Metabolic Alkalosis Causes - ANSWER-Vomiting Respiratory Alkalosis Causes - ANSWER-Hyperventilation/Mechanical Vent Respiratory Acidosis Causes - ANSWER-Decreased rest stimuli (ex-anesthesia), COPD, Pneumonia, Atelectasis Metabolic Acidosis Causes - ANSWER-DKA, Renal failure, Dehydration, Liver failure, Diarrhea, Fistulas Normal pH - ANSWER-7.35-7. PaCO2 normal levels - ANSWER-35- HCO3 - ANSWER-22- Trach Care - ANSWER-Q8H or PRN; hyper O2 prior, suction, remove old dressings, open sterile teach care kit/sterile glove, remove inner cannula (clean with hydrogen peroxide), reinsert, clean stoma with hydrogen peroxide and sterile water, change ties, new sterile dressing (DONT CUT GAUZE)

answers 2024

Nasal Cannula - ANSWER-1-6L/min Face Mask - ANSWER-6-8L/min Partial Rebreather - ANSWER-8-11L/min Nonrebreather - ANSWER-12L/min Venturi Mask - ANSWER-4-8L/min Trach Collar - ANSWER-8-10L/min Ear Drops for adult vs child - ANSWER-Up and back with adult; down and back for child! After lie on unaffected ear to facilitate absorption NGT Insertion - ANSWER-Measure distance from tip of nose to earlobe to bottom of xiphoid process; mark the end with tape ~lubricate, insert through nose, offer sips of water/bend head forward (HOB 60-90 degrees) ~secure with hypoallergenic tape MONITOR FOR RESP DISTRESS! (sign that it is misplaced in the lungs) NGT Verication - ANSWER-VERIFY WITH CHEST XRAY ~Aspirate gastric contents and check pH (should be <4 if gastric location)

answers 2024

NGT Care - ANSWER-Check residual before feedings and Q4H if continuous feeding (hold feeding if >100mL); 15-30mL water before and after each med and feed; admin fluids at room temperature; change bag Q24-72H; HOB 30 when feeding and 30 min post Urinary Catheter Insertion (Female) - ANSWER-explain; assemble equipment, pt in dorsal recumbent position or Sims Drape with drapes using sterile tech; sterile gloves; lube catheter; place in tray. Separate labia and wipe from meatus towards rectum with iodine swabs; insert 2-3 inches into urethrea after seeing urine; inflate balloon; gentile traction/tape to thigh Urinary Catheter Insertion (Male) - ANSWER-explain; assemble equipment, pt in dorsal recumbent position or Sims Drape with drapes using sterile tech; sterile gloves; lube catheter; place in tray. Pull foreskin and cleanse in circular motion; hold penis perpendicular to body; insert catheter 6-7 inches; replace foreskin; inflate; tape Self Catheterization - ANSWER-Keep catheter 2-4 weeks, make sure to do Q 4- Hrs on a schedule; can do sitting or standing; hydrate When would you use defibrilation vs cardioversion - ANSWER-Defib for V fib (paddle at R sternal border and over apex of heart) and give 1 mg Epi IVP Q3- min Cardioversion for arrhythmias like Afib (need informed consent) S/S of shock - ANSWER-Cool/clammy skin; restless; tachycardia; weak pulses; Metabolic Acidosis; Oliguria; shallow/rapid respirations; muscle weakness

answers 2024

Fluid volume deficit S/S - ANSWER-thirst (early sign), fever, rapid/weak pulse, increased resp, hypotension, weight loss, anxiety, decreased output, HA, increased specific gravity Fluid volume overload S/S - ANSWER-increased/bounding pulse, periph edema, HTN, muffled heart sounds, JVD, low spec gravity, increased venous pressure, decreased Hct/Hgb/BUN/Na DI - ANSWER-decreased ADH- have excessive urine output, dehydration, thirst, weight loss, weakness, consta, low spec gravity, high Na ~NI=I&O, monitor spec gravity and DDAVP/Pitressin SIADH - ANSWER-increased ADH- have anorexia/N/V, decreased output, lethargy, HA, decreased DTR, tachy, decreased NA ~NI= restrict intake to 500mL/24 Hr, hypertonic saline, weights, I&O, assess LOC Hypokalemia - ANSWER-<3.5- can cause anorexia/N/V, weakness, dysrhythmias ~Supplements/increase intake (bananas, rasins, apricots, oranges, potatoes, carrots, celery) Hyperkalemia - ANSWER->5- can cause cardiac arrest, muscle weakness, paralysis, N/D ~Restrict meds with K and foods with K, give sodium polystyrene sulfonate, dialysis, or diuretics Hyponatremia - ANSWER-<135- can have N, muscle cramps, increased ICP, muscle twitching, confusion

answers 2024

~Increase intake (beef broth, tomato juice), IV LR or NS, water restriction, I&O, weights Hypernatremia - ANSWER->145- can have fever, delusions, disorientation, thirst, postural hypotension, HTN, tachy ~Give hypotonic solution, decrease NA intake, weight Hypocalcemia - ANSWER-<8.6- can have confusion, seizures, irritability ~Trousseau's Sign= inflate BP cuff to 20mmHg and have carpal spams= tetany ~Chvostek's Sign= tap facial nerve 2cm anterior to the earlobe= twitching of facial muscles=tetany ~Caution with IV CA! Causes irritation! maintain airway- can have stridor, seizure precautions!! Give vit D also! Exercise Hypercalcemia - ANSWER->10.2- can have muscle weakness, lack of coordination, constipation, depressed reflexes, dysrhythmias ~Important to mobilize patient, increase fluids, and prevent injury and renal calculi formation! Hypomagnesemia - ANSWER-<1.3- can have tremors, tetany, seizures, depression, confusion! MG DEPRESSES CNS! ~Increase intake (green veggies, nuts, bananas, oranges, pb, chocolate), monitor cardiac! monitor for dig toxicity! seizure precautions! Test ability t swallow bc dysphagia! ~Can give Ca to counteract danger of myocardial dysfunction that can occur from mag toxicity and rapid infusions!

answers 2024

Hypermagnesemia - ANSWER->2.3- can have hypotensions, facial flushing, weakness, absent DTR, paralysis, deep/shallow respitations EMERGENCY! ~Give IV Calcium gluconate, dialysis, monitor cardiac rhythms, support ventilations; teach pt about OTC drugs that have mag Rule of 9s - ANSWER-head= front torso= back= each leg= each arm= groin= Addison's Disease - ANSWER-Hyposecretion of adrenal hormones (mineralcorticoids, glucocorticoids, and androgens) S/S of Addison's - ANSWER-weakness, dehydration, falling BP--> shock/coma/death, hyperpigmentation, weight loss, fractures, depression/lethargy, decreased BP--> insulin shock ~Hormone replacement and high protein and carb and Na/low K Cushing's Disease - ANSWER-Hypersecretion of adrenal hormones (mineralcorticoids, glucocorticoids, and androgens) S/S of Cushing's - ANSWER-fatigue, weakness, muscle wasting, purple skin striation, depression, moon face, buffalo hump, masculinazation in females, blood sugar imbalance (increased), can have hyperactivity ~Need surgery and K/low Na/Cal/Carb diet

answers 2024

R sided HF S/S - ANSWER-affects periphery; dependent edema, hepatomegaly, cool extremities, anxiety, depression, weight gain L sided HF S/S - ANSWER-affects lungs; dyspnea, orthopena, pleural effusion, cheyne stokes respirations, crackles, cough with frothy bloody sputum, fatigue, weakness, cerebral anoxia--> ALOC Venous Vascular Diseases - ANSWER-Varicose veins, Thrombophlebitis (will be cool/brown and have pain)= elevate legs! use warm/moist packs Arterial Vascular Diseases - ANSWER-Atherosclerosis, Raynaud's, Buerger's (will be cool/shiny/cyanotic/pallor)= legs in dependent position; don't cross legs/no smoking S/S of anemia - ANSWER-dyspnea possible; pale, exhaustion, loss of appetite, cold sensitivity, dizziness, HA ~ID and treat cause Complication of Dwarfism - ANSWER-Diabetes Complication of Acromegaly - ANSWER-Poor vision/coordination- need to provide safety Warning signs of Cancer - ANSWER-Change in bowel/bladder A sore that does not heal Unusual bleeding or discharge

answers 2024

Thickening or lump in tissue Indigestion or difficulty swallowing Obvious change in wart/mole Nagging cough or hoarseness Bradytherapy - ANSWER-Internal Radiation=limit contact to 30 minutes! Radiotherapy - ANSWER-External Radiation= avoid lotions/creams/deodorants/perfumes, clean and assess skins, don't expose to sunlight! Wear cotton clothes! Neutropenia Precautions - ANSWER-Assess skin integrity Q8H, private room, hand hygiene, no sick visitors, no standing water/flowers, clean room daily, low microbial diet (no salads, peeled fruit/veggies), deep breathing Q4H, body hygiene, inspect IV site Assisting a patient out of bed - ANSWER-Place hand under knees and shoulder of patient; instruct pt to push elbow into bed at the same time the nurse should life pt shoulders with one arm and swing legs over edge with the other Assisting a patient to stand - ANSWER-Face the pt with hands grasping each side of rib cage; push nurse's knees against 1 of the pt's; rock pt forward to standing; pivot to sit in a chair (have chair on pts strong side) Assisting a patient into bed - ANSWER-move pt towards stronger side; use legs not back; use draw sheets as needed; always have assistant standing by!

answers 2024

Position for prolapsed cord - ANSWER-Trendelnberg (legs higher than head)or knee to chest Position for shock - ANSWER-Modified Trendelenburg (Feet elevated 20 degrees; knees straight; trunk flat; head slightly elevated) Position for suppositories - ANSWER-Sims (side lying with upper leg bent) Position for patient experiencing respiratory distress - ANSWER-HOB 60- degrees Position to allow for oral secretion drainage - ANSWER-Side lying Position post tube feeding - ANSWER-HOB up; R side to promote gastric emptying Position for foley insertion - ANSWER-Dorsal Recumbent (supine with knees flexed) Positon for liver biopsy - ANSWER-Supine with arms above head Position for suspected air embolism - ANSWER-HOB down; L side Positon for mom if fetal bradycardia - ANSWER-L side (also give mom O2 and start IV) indicated compression of vena cava/decreased O2 to baby

answers 2024

Using crutches - ANSWER-Support weight on hand piece! Keep crutches 8- inches out to the side; elbows flexed 20-30 degrees UP= good leg then crutches DOWN= crutches with bad leg then good leg Using a walker - ANSWER-Flex elbows 20-30 degrees; lift and move walker forward 8-10 inches; step forward with affected leg Nurse should stand behind pt SIT= grasp armrest on affected side; shift weight to good leg and hand; lower to chair Using a cane - ANSWER-Flex elbow 30 degrees and hold handle; tip of cane should be 15cm lateral to the base of the 5th toe Hold in hand opposite affected extremity; advance cane and affected leg together; lean on cane when moving good leg UP= cane and good leg DOWN= cane and bad leg Precautions with Pediculosis/Scabies - ANSWER-Contact Isolation Precautions with Samonella - ANSWER-Contact Isolation Precautions with Pertussis - ANSWER-Droplet Isolation Precautions with RSV - ANSWER-Contact Isolation

answers 2024

Precautions with TB - ANSWER-Airborne Isolation Precautions with Mumps - ANSWER-Droplet Isolation Precautions with MRSA - ANSWER-Contact Isolation Precautions with Hepatitis - ANSWER-Standard Isolation (Contact if diapered) Precautions with Herpes Simplex/Zoster - ANSWER-Contact Isolation Precautions with CMV (Cytomegalovirus) - ANSWER-Standard + wear goggles when handling urine Precautions with Influenza B - ANSWER-Droplet Isolation Precautions with C.Diff - ANSWER-Contact Isolation Precautions with Meningitis - ANSWER-Droplet Isolation until 24 H of treatment Precautions with Measles - ANSWER-Airborne Isolation Precautions with Rotavirus - ANSWER-Contact Isolation

answers 2024

Precautions for a patient post kidney transplant - ANSWER-Protective Isolation (no visitors!) for 72 H Precautions with Pneumonia - ANSWER-Droplet Isolation Precautions with Shingles/Chickenpox - ANSWER-Airborne Isolation Precautions with a suspected infected decubitus ulcer - ANSWER-Contact Isolation Diet with lithium therapy - ANSWER-Increase NA Therapeutic lithium level - ANSWER-1-1. S/S of lithium toxicity - ANSWER-N/V/D, fine tremors, slurred speech IV Pyleogram - ANSWER-XRay of urinary tract D/C metformin 48H prior, do cleansing enema night prior Duodenal Ulcers S/S - ANSWER-Pain 1H after meal Gastric Ulcers S/S - ANSWER-Pain prior to meal and 2-3H after and during the night Autonomic Dysreflexia - ANSWER-Severe HA, HTN, sweating, congestion, bradycardia

answers 2024

Seen with SCI- triggered by cold Buerger's Disease - ANSWER-Inflammation/thrombosis in blood vessels (associated with smoking)- will have digital sensitivity to the cold Miller Abbot Tube - ANSWER-Removes fluid from small intestine- used for intestinal decompression and paralytic illeus treatment Enwald Tube - ANSWER-For rapid lavage; have suction ready! If a patient in PostPartum's fundus is boggy and displaced to the R what should the nurse do? - ANSWER-Tell the patient to use the restroom What does restlessness/overactiveness in kids give a clue to? - ANSWER-Pain What is the Cerebellum responsible for? - ANSWER-Balance What is the Occipital Lobe responsible for? - ANSWER-Vision What is the Parietal Lobe responsible for? - ANSWER-Sensory Discrimination What is the Temporal Lobe responsible for? - ANSWER-Hearing What is the Frontal Lobe responsible for? - ANSWER-Concentration, Language, Personality

answers 2024

Irritable Bowel Syndrome S/S - ANSWER-Alternating diarrhea and constapation Inflammatory Bowel Disease - ANSWER-Chronic diarrhea and vomiting ECT - ANSWER-Done for seizures, depression Use general anesthesia, electric currents travel through brain to trigger brief seizure (back pain after not normal) -give Atropine 30 min prior to decrease secretions Electromyography - ANSWER-30 min; noninvasive- electrodes attached to legs and measure impulse transmission EEG - ANSWER-Electroencephalogram- tracks brain waves/seizure acitivty- want patient sleep deprived prior so they can sleep during exam What effect does digoxin have on Potassium? - ANSWER-Lowers blood concentration of K; if given with low K there is an increased risk for toxicity S/S of hiatial hernia - ANSWER-Awaken with heart burn CF diet - ANSWER-High calorie, high protein Myleogram - ANSWER-Lumbar puncture with contrast and use XR to see vertebral column Post= increase PO fluids, lie flat, VS

answers 2024

Common symptoms experienced with dialysis - ANSWER-Pain on inflow, constipation What does cloudy outflow of dialysalate indicate? - ANSWER-Peritonitis S/S of narcotic withdrawal - ANSWER-Flu-like symptoms Can head injury patients have narcotics? - ANSWER-NO! Masks the S/S of increased ICP! S/S of increased ICP in children - ANSWER-high pitched cry or bulging fontanelles (before closure) Anterior fontanelle closes at - ANSWER-18MO Posterior fontanelle closes at - ANSWER-2MO Assessment post Cardiac Cath - ANSWER-Pulses! Check pulses distal to insertion! IV Lock Implementation - ANSWER-Give 2-3mL NS before the med Should you give insulin preop? - ANSWER-No hold and let a sliding scale be used as needed!

answers 2024

Diet post op to promote wound healing - ANSWER-High protein, calorie, and vitamin C L:S Ratio - ANSWER-2:1 is the goal! (>2) indicative of lung maturity in fetus Pregant and lying down - ANSWER-Increases vena cava pressure= decreasing bloodflow to fetus Should care be clustered with increased ICP patients? - ANSWER-No- space out to allow rest periods TPA Rules - ANSWER-Contra with trauma w/in 2 months; Must be given w/in 3 hours of onset of symptoms! Implementation for hypokalemia - ANSWER-First= put patient on monitor; Second= give K replacement Counting HR on EKG - ANSWER-Count small boxes between R wave= # #/1500= HR Should a patient deep breathe during CVC insertion? - ANSWER-No- causes a valsalva maneuver! How often should the need for restraints be re-evaluated? - ANSWER-Q4H Recommended fluid intake per day - ANSWER-1,500-2,000

answers 2024

Care for patient with meningitis - ANSWER-Quiet/dark room, frequent LOC checks, decrease fluids d/t increased ICP Myasthenia Gravis S/S and NI - ANSWER-Muscle weakness, impaired speech, RESPIRATORY DISTRESS Give medications before eating; must take on time! Can go into Crisis (cant maintain airway!) Avoid heat, Provide rest periods, Assess/Assist towards end of the day (get tired) Multiple Sclerosis S/S and NI - ANSWER-Vision/motor/sensory, cognitive, bladder/bowel changes, tremors, muscle weakness Warm baths/packs, wide based walk is safer, practice coordination exercises, eye patch if diplopia Amyotrophic Lateral Sclerosis S/S and NI - ANSWER-Progressive degeneration of motor neurons/system Can have spastic and atrophic changes in movement, dysphagia, aspiration risk!!!! Progressive weakness/wasting! Can have muscle twitching= respiratory insufficency! Maintain nutrition, self care, support, adapt home environment Gullian Barre Syndrome S/S and NI - ANSWER- Post Hip Replacement care - ANSWER-Maintain ABDuction, avoid stooping, dont sleep on operated side, never cross legs, avoid flexion, walk, resume ADLs in 3months

answers 2024

Ventricular Tachycardia - ANSWER-Lidocaine (if pulseless= Epi then Amnioderone) Supraventricular Tachycardia - ANSWER-Vagal maneuver and Adenosine Unstable ventricular dysrhythmias - ANSWER-Cardiovert! Ventricular Fibrilation - ANSWER-Lidocaine (if pulseless= Epi then Amnioderone) Bradycardia - ANSWER-Give Atropine then Epi or Dopamine Atrial Fribrilation - ANSWER-Give Amino Acids, BB, CCB, and Digoxin Atrial Flutter - ANSWER-Give Amino Acids, BB, CCB, and Digoxin