NCLEX-RN Revision Questions and Answers: A Comprehensive Guide for Nursing Students, Exams of Nursing

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NCLEX RN REVISION QUESTIONS AND ANSWERS

Is a process of learning a different culture to adapt to a new or changing environment. – answer Acculturation. It is a subjective perspective of the person's heritage and a sense of belonging to a group – answer Ethnic identity Include meditation, relaxation techniques, imagery, music therapy, massage, touch, laughter, humor, & spiritual measures (prayer). – answer Low-risk therapies: Because of their health & dietary practices, Native Americans, Latino Americans, Hispanic Americans, & African Americans. – answer High risk of obesity & diabetes mellitus Surgery is not prohibited, but the administration of blood and blood products is forbidden. This religious group believes the soul cannot live after death. Administration of medication is an acceptable practice except if the medication is derived from blood products. – answer Jehovah's Witnesses Believers adhere to dietary kosher laws. In this religion, the dairy-meat combination is unacceptable. Only fish that have scales and fins are allowed; meats that are allowed include animals that are vegetable eaters, cloven- hoofed, and ritually slaughtered. – answer Orthodox Judaism include whole medical systems, mind-body medicine, biologically based practices, manipulative & body-based practices, & energy medicine. – answer Five categories of complementary and alternative medicine (CAM): Focused, maintains strong control, makes decisions, & addresses all problems. Dominates group & commands, rather than seeks suggestions or input. Manager addresses problem (quality improvement) with staff, designs a plan without input, & wants all problems reported directly back to her – answer Autocratic leader

Participative & would likely meet with each staff person individually to determine staff member's perception of problem. Would also speak with the staff about any issues & ask the staff for input with developing a plan. – answer Democratic leader Passive and nondirective. Would state what the problem was & inform staff that the staff needed to come up with a plan to "fix it." – answer Laissez-faire leader Assessment findings include cough, dyspnea, crackles, tachypnea, tachycardia, elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck & hand vein distention, altered LOC, & decreased hematocrit. – answer Overhydration or fluid overload & occurs when fluid intake or fluid retention Avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork, beef, veal, raisins, spinach, strawberries, & tomatoes – answer Common food sources of potassium: Muscle weakness, increased urinary output, & decreased specific gravity of the urine would be noted – answer Hyponatremia Causative factors relate to malnutrition or starvation & the use of aluminum hydroxide-based or magnesium-based antacids. Malnutrition is associated with alcoholism. – answer Hypophosphatemia Renal insufficiency, hypoparathyroidism, & tumor lysis syndrome; causative factors. Should avoid foods high in phosphates; fish, eggs, milk products, vegetables, whole grains, & carbonated beverages. – answer Hyperphosphatemia Vomiting, diarrhea, conditions that increased respiration's or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, presence of ileostomy or colostomy. Diuretics, & gastrointestinal suctioning. - answerCauses of a fluid volume deficit

irrigation of wounds & body cavities, & excessive ingestion of sodium. - answerCauses of overhydration or fluid overload: Trauma, burns, sepsis, or metabolic or respiratory acidosis. - answerHyperkalemia causes: Cushing's syndrome or colitis & over use of laxatives. - answerHypokalemia causes: Decreased pH & decreased HCO3. Occurs in kidney disease; diabetic ketoacidosis; high fat diet; insufficient metabolism of carbohydrates; malnutrition; ingestion of toxins, such as acetylsalicylic acid (aspirin); malnutrition; severe diarrhea. Intestinal secretion high in bicarbonate & may be lost through enteric drainage tubes, an ileostomy, or diarrhea. - answerMetabolic acidotic Nausea & vomiting. Loss of gastric acid, cause pH & HCO3 to increase. Symptoms experienced would include hypoventilation & tachycardia. - answerMetabolic alkalosis Decreased pH and an increased CO2. Hypoventalation & COPD - answerRespiratory acidotic Increased pH & decreased CO2. Hyperventalation, Lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, numbness & tingling of extremities. Hyperventilation (tachypnea) occurs. - answerRespiratory alkalotic Sample for PT & INR level to determine anticoagulation status & risk for bleeding - answerWarfarin (Coumadin) aPTT monitors the effects. Anticoagulant used most often during hemodialysis. Monitors extent of anticoagulation checking PTT, which is appropriate measure heparin effect. Protamine sulfate is antidote. - answerHeparin Dark green leafy vegetables good source iron, oranges are a good source of

vitamin C, which enhances iron absorption. - answerIron deficiency anemia foods in diet:

blood vessel. Weight monitored

for effectiveness nutritional therapy & detect hypervolemia. - answerParenteral nutrition; PN monitor Burns, exacerbation Crohn's disease, persistent nausea & vomiting due to chemotherapy. Had extensive surgery, multiple fractures, are septic, have advanced cancer or AIDS. (Electronic infusion pump used to administer) - answerParenteral nutrition; Patients needing 10% dextrose in water until new PN solution becomes available. - answerParenteral nutrition; If PN bag empty hang IV dislodged from vein & is lying in subcutaneous tissue. Pallor, coolness, & swelling are results of IV fluid being deposited in tissue. Corrective action is remove catheter & start new IV line at another site. - answerInfiltrated IV Discomfort at site, redness, warmth, & swelling proximal to catheter. If phlebitis occurs, discontinue IV line & insert new IV line at different site. Apply warm moist compresses to area speed resolution of inflammation. Notify (HCP). Document occurrence, actions taken, & client response. - answerPhlebitis at IV site: Produces a rash, redness, & itching. - answerAn allergic reaction at IV site: Characterized by ecchymosis, swelling, & leakage at IV insertion site, as well as hard & painful lumps at site. - answerHematoma Dyspnea, a swollen tongue, & cyanosis. - answerHypersensitivity reaction: Taught minor activity restrictions apply with this type of catheter. Protect site during bathing & should carry or wear Medic-Alert ID. Have repair kit in home for use as needed because catheter is for long-term use. - answerPICC line Before beginning administration IV solution, assess whether chest radiograph reveals central

Preconventional stage, morals are thought to be motivated by punishment & reward. - answerKohlberg's theory of moral development Should not try anticipate newborn infant needs but allow newborn infant to signal needs. If newborn infant is not allowed to signal a need, newborn will not learn how to control environment. Delayed or prolonged response to newborn infant's signal would inhibit development trust & lead to mistrust of others - answerErikson's psychosocial development theory Child has the ability to think abstractly and logically. - answerFormal operations stage of Piaget's cognitive developmental theory Child begins to understand the environment. - answerPaiget's sensorimotor stage Child is able to classify, order, and sort facts. - answerPaiget's concrete operational stage Child learns to think in terms of past, present, & future. - answerPaiget's preoperational stage 20 to 40 breaths/minute - answerNormal respiratory rate in a 12-month-old 90 to 130 beats/minute - answerNormal apical heart rate in a 12-month-old 90/56 mm Hg - answerAverage blood pressure in a 12-month-old Diamond-shaped & located on top of head. Soft & flat in normal infant, & it normally closes by 12- 18 months of age - answerAnterior fontane Decreased lean body mass & age-associated decreased glomerular filtration rate. - answerolder client is at risk for medication toxicity because

Stand feet together & arms at sides, close eyes & hold position; normally client can maintain posture & balance. Positive Romberg's sign is a vestibular neurological sign found when client exhibits loss balance when closing eyes. - answerRomberg's test Rhythmic respirations with periods of apnea. Periods apnea followed by deep rapid breathing - answerCheyne-Stokes respirations Physical obstruction to transmission of sound waves - answerConductive hearing loss occurs as result pathological process in inner ear, defect in 8th cranial nerve, or defect of sensory fibers that lead to cerebral cortex. - answerSensorineural hearing loss Abnormal heart sound & described as gentle, blowing, swooshing sound. - answerHeart murmur Described as a scratchy, leathery heart sound. - answerPericardial friction rub Tests the six cardinal positions of gaze - answerAssess for muscle weakness in eyes Visual acuity & cranial nerve II (optic). - answerSnellen eye chart Close eyes & then lightly touching areas of face & testing corneal reflexes assess cranial nerve V (trigeminal). - answerTesting sensory function tested insupine position. Flexes head (gently moves head to chest) & there should be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed if passively flexes hip & knee in response to neck flexion & reports pain in vertebral column. - answerPositive Brudzinski's sign Blood leaves embryo through two umbilical arteries. Oxygenated, blood returned

oxygenated blood & provides oxygen & nutrients to fetus. - answerFetal circulation Connects umbilical vein to inferior vena cava - answerDuctus venosus Is temporary opening between right & left atria. - answerForamen ovale Joins the aorta & pulmonary artery - answerDuctus arteriosus Uterine enlargement, Hegar's sign , Goodell's sign , Chadwick's sign, ballottement, Braxton Hicks contractions, & positive pregnancy test for presence of HCG. - answerProbable signs of pregnancy Fetal heart rate detected by electronic device (Doppler transducer), active fetal movements palpable by examiner, & outline fetus by radiography or ultrasonography. - answerPositive signs of pregnancy *Pregnancy avoided for 1-3 months. Vaccine administered subcutaneous route.Exposure immunosuppressed individuals avoided. *Hypersensitivity reaction can occur if client has allergy to eggs. - answerRubella virus vaccine Postpartum Three classic signs are hypertension, generalized edema, & proteinuria. - answerClassic signs of preeclampsia Can trigger disseminated intravascular coagulation (DIC). Evidence of bleeding, such as in gums, petechiae, & purpura should be reported to HCP if noted on assessment. - answerSevere preeclampsia Considered a risk factor for disseminated intravascular coagulation (DIC). - answerDead fetus syndrome Isoniazid plus rifampin (Rifadin) will be required for 9 months. - answerPregnant

client

trimester pregnancy symptom. (Sudden onset painless vaginal bleeding) - answerPlacenta previa

Oxygen administered, 8 to 10 L/min, by face mask. Oxygen used decrease hypoxia. Kept on bed rest with head of bed slightly elevated reduce dyspnea. Morphine sulfate may be prescribed, not initial nursing action. IV also required, & vital signs need to be monitored, but these actions would follow administration of oxygen. - answerPulmonary embolism is suspected Infection of bladder. Should consume 3000 mL of fluids per day if not contraindicated. - answerCystitis May present clinical signs of cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible grunts. - answerNewborn infant with respiratory distress syndrome Bluish discoloration of hands & feet, is associated with immature peripheral circulation, & common in first few hours of life. - answerAcrocyanosis Craniofacial abnormalities, intrauterine growth restriction, cardiac abnormalities, abnormal palmar creases, & respiratory distress. Hypotonia, irritability, & poor sucking reflex. - answerFetal alcohol syndrome May exhibit hyperirritability, vomiting, diarrhea, or uncoordinated sucking & swallowing ability. Quiet environment with minimal stimuli & handling would help establish appropriate sleep-rest cycles in newborn as well. - answerFetal alcohol syndrome Used as prophylactic treatment for ophthalmia neonatorum, which is caused by bacterium Neisseria gonorrhoeae. Preventive treatment of gonorrhea is required by law - answerErythromycin ophthalmic ointment Central nervous system depressant & relaxes smooth muscle, including uterus. Used to halt preterm labor contractions & used for preeclamptic clients to prevent seizures. Adverse effects include flushing, depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle weakness, decreased urine output, pulmonary edema, & elevated serum magnesium levels.

Glucocorticoid, given increase production of surfactant to stimulate fetal lung maturation. Administered clients preterm labor at 28 to 32 weeks of gestation if labor can be inhibited for 48 hours. - answerBetamethasone (Celestone) Opioid analgesic. - answerNalbuphine (Nubain) Given to Rh-negative clients to prevent sensitization. - answerRho(D) immune globulin (RhoGAM) Prostaglandin given ripen & soften cervix & stimulate uterine contraction - answerDinoprostone (Cervidil vaginal insert) Respiratory Distress Syndrome serious lung disorder caused by immaturity & inability to produce surfactant, resulting in hypoxia & acidosis. Common premature infants & may be due to lung immaturity: result of surfactant deficiency. Mainstay treatment administration exogenous surfactant, administered by intratracheal route - answerBeractant (Survanta) Opioid antagonist, which reverses effects of opioids & given for respiratory depression. - answerNaloxone Appears burrows or fine, grayish red, threadlike lines. May be difficult to see if they are obscured by excoriation & inflammation. Multiple straight or wavy, threadlike lines beneath skin. Wear a gown & gloves for close contact. - answerScabies Clusters of fluid-filled vesicles - answerHerpesvirus infection Contagious bacterial infection skin. Common during hot, humid summer months. May begin area broken skin, such as an insect bite or atopic dermatitis. Impetigo very contagious. Lesions usually located around mouth & nose, but may be on hands & extremities. Mupirocin(Bactroban) topical antibacterial agent active against impetigo. - answerImpetigo

Group bleeding disorders resulting from deficiency specific coagulation proteins Abnormal laboratory results indicate prolonged partial thromboplastin time. Female offspring of affected male & carrier female are at risk for hemorrhage once puberty is attained & menstrual cycles begin, depending on severity of hemophilia, hysterectomy or ablation may be performed - answerHemophilia Classified as antidote for acute iron toxicity. - answerDeferoxamine (Desferal) Early sign slight change LOC, headache, nausea, vomiting, visual disturbances (diplopia), seizures. Late sign ICP include significant decrease LOC, bradycardia, decreased motor & sensory responses, alterations pupil size & reactivity, posturing, Cheyne-Stokes respirations, & coma. - answerSymptom of increased ICP Confirmatory test for leukemia is microscopic examination of bone marrow obtained by bone marrow aspirate & biopsy. - answerLeukemia Malignancy lymph nodes. Presence of giant, multinucleated cells (Reed-Sternberg cells) is classic characteristic of this disease. - answerHodgkin's disease Never be administered in the presence of oliguria or anuria. Checks amount urine output before administration. - answerpotassium chloride Also known as congenital aganglionosis or megacolon. Pellet or ribbon-like stools: foul-smelling is clinical manifestation of disorder. Delayed passage or absence of meconium stool in neonatal period also a sign. Bowel obstruction in neonatal period, abdominal pain & distention, & failure to thrive also clinical manifestations.

• answerHirschsprung's disease Projectile vomiting, irritability, hunger & crying, constipation, & signs dehydration including decrease urine output. - answerPyloric stenosis Invagination of section of intestine into distal bowel. Most common cause of bowel obstruction