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NCLEX Review
| Question | Answer |
|---|---|
| What are the six steps of the NCSBN Clinical Judgment Measurement Model? | Recognize cues; analyze cues; prioritize hypotheses; generate solutions; take action; evaluate outcomes. |
| When reviewing a case, what is the purpose of recognizing cues? | Identify relevant assessment findings, history, labs, and trends that may signal a problem. |
| How should the nurse prioritize hypotheses? | Rank likely problems by immediacy, threat to life, and risk of harm. |
| What makes a generated solution strong? | It targets the priority problem, is evidence-based, is safe, and has a measurable outcome |
| How should the nurse sequence actions? | Address life-threatening and time-sensitive problems first, then reassess before moving to lower priorities. |
| What is the key question in evaluating outcomes?intervention? | Did the client improve as expected, remain unchanged, or worsen after the |
| Which client usually has priority: acute or chronic? | The client with an acute change, unless the chronic client is unstable. |
| Which client usually has priority: unstable or stable? | The unstable client. |
| When should the nurse assess before intervening? | Assess first when more data are needed and there is no immediate threat requiring emergency action. |
| When should the nurse act before completing a full assessment? | When a clear airway, breathing, circulation, safety, or other life-threatening emergency is present. |
| What does an NCLEX “first” question require? | The safest action that begins the correct sequence of care. |
| What is a useful way to study pharmacology? | For each major drug, know its purpose, three priority adverse effects or concerns, and essential monitoring or teaching. |
| What should the nurse do when two answer choices seem correct? | Choose the option that addresses the priority problem most directly with the least risk. |
| What findings suggest fluid volume deficit? | Tachycardia, orthostatic hypotension, dry mucosa, decreased urine output, weight loss, poor skin turgor, and concentrated urine. |
| What findings suggest fluid volume excess? | Weight gain, edema, crackles, dyspnea, bounding pulse, jugular venous distention, and possible hypertension. |
| How much fluid does a 1-kg change in body weight represent? | Approximately 1 liter of fluid. |
| What urine output generally requires prompt adult assessment? | Inadequate tissue perfusion progressing to hypovolemic shock. |
| What is the priority concern with severe hypovolemia? | Airway and breathing assessment, side positioning, oxygen/suction as needed, |
| What are priority actions for symptomatic fluid volume deficit? | Assess perfusion, obtain vital signs, establish IV access, replace fluid as ordered, monitor urine output, and treat the cause. |
| What are priority actions for fluid volume excess with dyspnea? | Position upright, assess oxygenation and lungs, apply oxLess than about 30 mL/hr or a downward trend, especially with signs of prescribed, give diuretics as ordered, and monitor response.poor perfusion.ygen as ordered, restrict sodium/fluids if |
| What neuromuscular findings occur with hypocalcemia? | Numbness or tingling, muscle cramps, hyperreflexia, tetany, and positive Chvostek or Trousseau signs. |
| What cardiac change may occur with hypocalcemia? | Prolonged QT interval and increased dysrhythmia risk. |
| What findings occur with hypercalcemia? | Weakness, lethargy, decreased reflexes, constipation, nausea, kidney stones, and dysrhythmias. |
| What phrase helps distinguish calcium imbalances? | Low calcium is excitable; high calcium slows and relaxes body systems. |
| What is a priority intervention for severe symptomatic hypocalcemia? | Place on cardiac monitoring, institute seizure precautions, and administer IV calcium as prescribed. |
| What safety concern applies to IV calcium? | Give slowly through a patent line and monitor for dysrhythmia and tissue injury. |
| What findings suggest hypomagnesemia? | Tremors, hyperreflexia, muscle cramps, seizures, irritability, and ventricular dysrhythmias. |
| What findings suggest hypermagnesemia? | Lethargy, hypotension, bradycardia, decreased reflexes, respiratory depression, and cardiac arrest. |
| What is the antidote for severe magnesium toxicity? | IV calcium gluconate, as prescribed. |
| What assessment is especially important during magnesium therapy? | Respiratory rate, deep tendon reflexes, urine output, blood pressure, and serum magnesium. |
| Why are potassium disorders dangerous? | They can cause life-threatening cardiac dysrhythmias and neuromuscular weakness. |
| What ECG findings are associated with hypokalemia? | Flattened or inverted T waves, ST depression, and prominent U waves. |
| What ECG findings are associated with hyperkalemia? | Tall peaked T waves, prolonged PR interval, widening QRS, and progression to lethal rhythms. |
| What are common causes of hypokalemia? | GI losses, diuretics, poor intake, insulin-related intracellular shift, and alkalosis. |
| What are common causes of hyperkalemia? | Kidney failure, potassium-sparing drugs, tissue breakdown, acidosis, and excessive replacement. |
| What are key rules for IV potassium? | Never give IV push; dilute it, use an infusion pump, verify urine output and kidney function, and monitor the IV site and rhythm. |
| What medications may be used to temporarily shift potassium into cells? | Regular insulin with dextrose and sometimes inhaled beta2 agonists; these do not remove potassium from the body. |
| What therapy stabilizes the cardiac membrane in severe hyperkalemia? | IV calcium, as prescribed; it protects the heart but does not lower serum potassium. |
| What organ system is most affected by sodium imbalance? | The neurologic system because sodium strongly influences water movement and brain-cell volume. |
| What findings suggest hyponatremia? | Headache, confusion, nausea, muscle cramps, lethargy, seizures, and coma when severe. |
| What findings suggest hypernatremia? | Intense thirst, dry sticky mucosa, restlessness, irritability, weakness, confusion, and seizures when severe. |
| Why must sodium be corrected gradually? | Rapid correction can cause severe neurologic injury from rapid fluid shifts. |
| What is the usual relationship between calcium and phosphorus? | They generally move in opposite directions; when one rises, the other often falls. |
| What is a major effect of severe hypophosphatemia? | Muscle weakness, including respiratory-muscle weakness, impaired cardiac function, and altered mental status. |
| What are normal arterial pH, PaCO2, and bicarbonate ranges? | pH 7.35-7.45; PaCO2 35-45 mm Hg; HCO3 22-26 mEq/L. |
| How do you identify respiratory acidosis? | Low pH with elevated PaCO2; think hypoventilation and CO2 retention. |
| How do you identify respiratory alkalosis? | High pH with low PaCO2; think hyperventilation and excessive CO2 loss. |
| How do you identify metabolic acidosis? | Low pH with low bicarbonate; causes include DKA, diarrhea, lactic acidosis, and kidney failure. |
| How do you identify metabolic alkalosis? | High pH with high bicarbonate; causes include vomiting, gastric suction, and some diuretics. |
| What does partially compensated mean? | The pH remains abnormal, but the opposite system has started changing to compensate. |
| What does fully compensated mean? | The pH is within range, but PaCO2 and bicarbonate are abnormal in opposite directions. |
| What is the priority in treating an acid-base disorder? | Correct the underlying cause while supporting oxygenation, ventilation, perfusion, and electrolyte balance. |
| Why is hypertension called a silent condition? | It may cause target-organ damage without noticeable symptoms. |
| What organs are damaged by uncontrolled hypertension? | Heart, brain, kidneys, eyes, and blood vessels. |
| What findings make severe hypertension an emergency? | New neurologic deficits, chest pain, acute dyspnea or pulmonary edema, confusion, vision change, or kidney injury. |
| What teaching supports safe antihypertensive therapy? | Take medication consistently, rise slowly, monitor BP, avoid abrupt withdrawal, and report adverse effects. |
| What is the underlying process in coronary artery disease? | Atherosclerotic plaque narrows coronary arteries and reduces myocardial oxygen supply. |
| What modifiable risks should the nurse address? | Smoking, hypertension, diabetes, dyslipidemia, inactivity, obesity, and unhealthy diet. |
| What symptoms may indicate myocardial infarction? | Chest pressure or discomfort, dyspnea, diaphoresis, nausea, weakness, or atypical fatigue and indigestion-like symptoms. |
| What is the priority diagnostic test for suspected acute coronary syndrome? | A 12-lead ECG obtained promptly, along with serial cardiac troponins. |
| Why are serial troponins ordered? | A single early value may be normal; trends help detect myocardial injury. |
| What is the priority nursing response to new chest pressure? | Stop activity, assess ABCs and vital signs, obtain an ECG, establish IV access, and activate the prescribed chest-protocol.pain |
| When is nitroglycerin unsafe? | With significant hypotension, certain right-ventricular infarctions unless directed, or recent phosphodiesterase-5 inhibitor use. |
| What early complication causes many sudden deaths after MI? | Ventricular dysrhythmias. |
| What findings suggest left-sided heart failure? | Crackles, dyspnea, orthopnea, cough, hypoxia, fatigue, and pulmonary edema. |
| What findings suggest right-sided heart failure? | Peripheral edema, jugular venous distention, hepatomegaly, ascites, and weight gain. |
| What home finding should a client report promptly? | Rapid weight gain, increasing edema, worsening dyspnea, or reduced activity tolerance based on the provider’s parameters. |
| What is the priority position for acute dyspnea from heart failure? | High-Fowler position with legs dependent if tolerated, while assessing oxygenation and initiating ordered treatment. |
| What must be monitored with loop diuretics? | Blood pressure, urine output, weight, potassium, magnesium, kidney function, and dehydration. |
| What is a key toxicity clue for digoxin? | Anorexia, nausea, confusion, visual changes, bradycardia, or dysrhythmias; risk increases with hypokalemia. |
| What is shock? | Inadequate tissue perfusion that prevents cells and organs from receiving enough oxygen. |
| What finding often appears early in shock? | Tachycardia with subtle mental-status or perfusion changes; hypotension may be a later sign. |
| What does an elevated lactate suggest? | Impaired tissue oxygenation and anaerobic metabolism; trend it with the clinical response. |
| What is the general initial approach to shock? | Support airway and oxygenation, establish IV access, restore circulating volume when appropriate, treat the cause, and monitor perfusion. |
| What supports suspected septic shock? | Possible infection plus hypotension or poor perfusion, altered mental status, oliguria, rising lactate, and abnormal temperature or WBC findings. |
| What therapies are time-sensitive in sepsis? | Cultures when they do not delay care, broad-spectrum antibiotics, IV fluids, lactate measurement, and vasopressors if hypotension persists. |
| What findings suggest deep vein thrombosis? | Unilateral swelling, warmth, redness, tenderness, and increased limb circumference. |
| What should the nurse avoid when DVT is suspected? | Do not massage the affected limb; limit manipulation and follow orders for diagnostic testing and anticoagulation. |
| What findings suggest pulmonary embolism? | Sudden dyspnea, pleuritic chest pain, tachycardia, hypoxemia, anxiety or impending doom, cough, or hemoptysis. |
| What is the first nursing response to suspected PE? | Support oxygenation, rapidly assess hemodynamic stability, notify the response team/provider, establish monitoring and IV prepare for ordered anticoagulation or reperfusion therapy.access, and |
| What does “time is brain” mean? | Rapid recognition, last-known-well time, imaging, and treatment can reduce permanent neurologic loss. |
| What must be determined immediately for a suspected stroke? | Exact last-known-well time, blood glucose, neurologic findings, anticoagulant use, and whether symptoms are evolving. |
| Why is a noncontrast head CT obtained urgently? | To distinguish ischemic from hemorrhagic stroke before thrombolytic or antithrombotic decisions. |
| What safety action is required before oral intake after stroke? | Keep the client NPO until swallowing is screened or evaluated. |
| What is innate immunity? | Immediate, nonspecific defense present at birth, including skin, mucous membranes, inflammation, and phagocytic cells. |
| What is adaptive immunity? | Specific immunity developed after exposure or vaccination through B and T lymphocytes and immune memory. |
| What laboratory trends commonly support inflammation or infection? | CBC with differential, cultures, C-reactive protein, and other findings interpreted with the clinical picture. |
| When should cultures ideally be obtained? | Before the first antimicrobial dose when feasible, without delaying urgent therapy. |
| What is the hallmark of nephrotic syndrome? hyperlipidemia. | Massive protein loss in urine causing hypoalbuminemia, edema, and |
| Why is infection risk increased in nephrotic syndrome? | Protective proteins may be lost in urine, and edema can impair tissue defenses. |
| What should the nurse monitor closely? | Daily weight, edema, skin integrity, urine protein, albumin, kidney function, and signs of infection or thrombosis. |
| What findings suggest pyelonephritis? | Fever, chills, flank pain, costovertebral-angle tenderness, nausea, and urinary symptoms. |
| What serious complications can occur? | Urosepsis, acute kidney injury, and renal abscess. |
| What teaching helps prevent recurrent urinary infection? | Hydrate if not restricted, void regularly and after intercourse, wipe front to back, avoid delaying urination, and complete antibiotics. |
| What findings suggest acute glomerulonephritis? | Hematuria or cola-colored urine, proteinuria, edema, hypertension, and reduced urine output. |
| What complications require close monitoring? | Pulmonary edema, severe hypertension, hyperkalemia, and acute kidney injury. |
| What is a classic finding in acute pancreatitis? | Severe epigastric pain often radiating to the back, with nausea and vomiting. |
| Which laboratory test is most specific for pancreatitis? | Serum lipase. |
| What are early priorities in acute pancreatitis? | NPO or bowel rest as ordered, aggressive IV fluids when appropriate, pain and nausea control, and monitoring for deterioration.respiratory or circulatory |
| What findings suggest appendicitis? | Pain migrating toward the right lower quadrant, anorexia, nausea, fever, and localized tenderness. |
| What should be avoided when appendicitis is suspected? | Laxatives, enemas, and heat to the abdomen because they may increase rupture risk. |
| What finding may indicate rupture? | Sudden change or temporary relief followed by worsening diffuse pain, rigid abdomen, fever, tachycardia, or signs of shock. |
| What findings suggest meningitis? | Fever, severe headache, neck stiffness, photophobia, vomiting, altered mental status, and possible petechial rash. |
| What isolation is used initially for suspected bacterial meningitis? | Droplet precautions in addition to standard precautions, per policy. |
| What is the priority when bacterial meningitis is suspected? | Obtain ordered cultures promptly and start prescribed antibiotics without avoidable delay; institute neurologic and seizure monitoring. |
| What findings suggest pneumonia? | Fever, cough, sputum, crackles, dyspnea, pleuritic pain, hypoxemia, fatigue, or acute confusion in older adults. |
| What diagnostic tests commonly support pneumonia evaluation? | Chest imaging, pulse oximetry, sputum culture when indicated, CBC, and blood cultures for severe illness. |
| What nursing interventions improve secretion clearance? | Hydration if allowed, coughing and deep breathing, mobility, incentive spirometry when appropriate, and prescribed bronchodilators or airway clearance. |
| What finding during tube feeding requires immediate action? | Coughing, choking, respiratory distress, decreased oxygen saturation, or suspected displacement; stop the feeding and assess. |
| How should a client be positioned for enteral feeding? | Head of bed elevated at least 30-45 degrees during feeding and for the prescribed period afterward. |
| What findings suggest pneumothorax? | Sudden pleuritic chest pain, dyspnea, tachycardia, decreased or absent unilateral breath sounds, and possible hypoxemia. |
| What findings suggest tension pneumothorax? | Severe respiratory distress, absent unilateral sounds, hypotension, distended neck veins, tracheal deviation as a late sign, and worsening hypoxia. |
| What is the priority treatment? | Immediate decompression followed by chest-tube placement; do not wait for routine imaging in an unstable client. |
| Where should the drainage system remain? | Below chest level and upright. |
| What does continuous bubbling in the water-seal chamber suggest? | An air leak; briefly assess the system and connections according to policy. |
| Should chest-tube tubing be routinely clamped? | No. Clamp only briefly for a specific approved reason or provider direction because clamping can cause tension pneumothorax. |
| What should the nurse do if a chest tube is pulled from the client? | Apply a sterile occlusive dressing, assess respiratory status, call for immediate help, and follow facility protocol. |
| What are hallmark findings of ARDS? | Acute respiratory distress, bilateral infiltrates, decreased lung compliance, and hypoxemia that is difficult to correct. |
| What is the central treatment goal? | Improve oxygenation while treating the cause and limiting ventilator-induced lung injury. |
| Why may prone positioning be used? | It can improve ventilation-perfusion matching and oxygenation in selected clients with severe ARDS. |
| What finding makes a PE unstable? | Hypotension, shock, severe hypoxemia, altered mental status, or cardiac arrest. |
| What findings suggest worsening asthma? | Increasing work of breathing, inability to speak full sentences, falling peak flow, hypoxemia, and decreasing breath sounds. |
| Why is a “silent chest” dangerous? | Minimal airflow may mean severe obstruction and impending respiratory failure. |
| Which inhaler is used for rapid relief? | A short-acting beta2 agonist such as albuterol, as prescribed. |
| What should be taught about inhaled corticosteroids? | Use consistently for control, rinse the mouth after use, and do not use them as the sole rescue treatment for acute bronchospasm. |
| What test supports diagnosis of cystic fibrosis? | Elevated sweat chloride, with genetic testing as indicated. |
| What are major treatment goals? | Mobilize thick secretions, prevent or treat infection, optimize nutrition, and replace pancreatic enzymes when needed. |
| When should pancreatic enzymes be taken? | With every meal and snack, according to the prescription. |
| What is a key oxygen safety rule? | Keep oxygen away from smoking, flames, sparks, petroleum products, and other ignition hazards. |
| What finding may indicate upper GI bleeding? | Hematemesis, coffee-ground emesis, melena, falling hemoglobin, tachycardia, or orthostatic hypotension. |
| What are the priorities for significant GI bleeding? | Assess ABCs and perfusion, keep NPO, establish large-bore IV access, obtain labs/type and screen, replace volume or blood and prepare for endoscopy.as ordered, |
| What medication class reduces gastric acid and promotes healing? | Proton-pump inhibitors. |
| What common infection is associated with many peptic ulcers? | Helicobacter pylori, treated with a prescribed multidrug eradication regimen. |
| What lifestyle teaching helps reduce reflux? | Avoid lying down after meals, eat smaller meals, identify triggers, elevate the head of bed, and reduce weight if appropriate. |
| What long-term complication may occur? | Esophagitis, stricture, or Barrett esophagus with increased cancer risk. |
| What findings suggest acute cholecystitis? | Right upper-quadrant pain, often after fatty food, nausea, fever, and possible pain to the right shoulder or back. |
| What complication is suggested by jaundice with biliary pain? | Possible common bile-duct obstruction, which needs prompt evaluation. |
| What assessments are important in hepatitis? | Fatigue, jaundice, dark urine, pale stool, right upper-quadrant discomfort, nutrition, bleeding, mental status, and liver tests. |
| What teaching protects the liver? | Avoid alcohol and unapproved acetaminophen or herbal products, take medications only as directed, and follow hepatitis type.transmission precautions for the |
| What findings suggest decompensated cirrhosis? | Ascites, jaundice, edema, varices, bruising or bleeding, confusion, asterixis, and muscle wasting. |
| What is hepatic encephalopathy? | Neurologic dysfunction from impaired hepatic detoxification, often presenting with confusion, behavior change, and asterixis. |
| How is lactulose evaluated in hepatic encephalopathy? | Improved mental status and the prescribed number of soft stools; monitor hydration and electrolytes. |
| What finding suggests ruptured esophageal varices? | Hematemesis or melena with tachycardia, hypotension, pallor, or altered mental status. |
| How does diverticulosis differ from diverticulitis? | Diverticulosis is the presence of pouches; diverticulitis is inflammation or infection of those pouches. |
| What diet is commonly encouraged after an acute episode resolves? | A gradual return to a high-fiber diet with adequate fluids if not contraindicated. |
| What findings suggest perforation? peritonitis. | Sudden severe generalized pain, rigid abdomen, fever, tachycardia, hypotension, or signs of |
| How does Crohn disease differ from ulcerative colitis? | Crohn disease can affect any GI segment with transmural skip lesions; ulcerative colitis is continuous mucosal inflammation of the colon beginning at the rectum. |
| What major complication is associated with ulcerative colitis? | Toxic megacolon, severe bleeding, perforation, and increased colorectal cancer risk. |
| What major complication is associated with Crohn disease? | Strictures or obstruction, fistulas, abscesses, and malnutrition. |
| What are the three broad causes of AKI? | Prerenal hypoperfusion, intrinsic kidney injury, and postrenal obstruction. |
| What findings require close monitoring in AKI? | Urine output, daily weight, creatinine/BUN trend, potassium, acid-base status, edema, lungs, and medication dosing. |
| What is the memory focus “U KILL” for renal assessment? | Urine output, potassium, intake and output, laboratory trends, and lung assessment. |
| What is a life-threatening electrolyte complication of AKI? | Hyperkalemia. |
| How does CKD differ from AKI? | CKD is a gradual, persistent loss of kidney function; AKI develops abruptly and may be reversible. |
| Why do clients with CKD develop anemia? | Damaged kidneys produce less erythropoietin. |
| What substances commonly accumulate as CKD advances? | Fluid, potassium, acids, phosphorus, and nitrogenous waste products. |
| What does cloudy peritoneal effluent suggest? | Peritonitis; assess for abdominal pain or fever, notify the provider, and obtain a specimen as ordered. |
| What should the nurse do when dialysate will not drain? | Check for kinks, clamps, constipation, and position; reposition the client and follow protocol. |
| What findings suggest benign prostatic hyperplasia? | Hesitancy, weak stream, dribbling, frequency, nocturia, incomplete emptying, and retention. |
| What complication requires urgent action? | Acute urinary retention with bladder distention and inability to void. |
| What finding after TURP is most concerning? | Bright-red bleeding with clots, decreased drainage, bladder distention, or signs of shock. |
| What findings define metabolic syndrome? | Central obesity, elevated blood pressure, elevated glucose or insulin resistance, high triglycerides, and low HDL. |
| What are major long-term risks? | Type 2 diabetes and cardiovascular disease. |
| How do type 1 and type 2 diabetes differ? | Type 1 involves autoimmune beta-cell destruction and absolute insulin deficiency; type 2 involves insulin resistance with ve insulin deficiency.progressi |
| What A1C value is diagnostic of diabetes when confirmed appropriately? | 6.5% or higher, interpreted according to diagnostic standards and clinical context. |
| What findings suggest hypoglycemia? | Sweating, tremor, hunger, tachycardia, irritability, confusion, weakness, seizure, or unconsciousness. |
| How is conscious hypoglycemia treated? | Give about 15 g of rapid-acting carbohydrate, recheck in 15 minutes, repeat if still low, then provide follow-up food as appropriate. |
| How is severe hypoglycemia treated when the client cannot swallow? | IV dextrose or glucagon per protocol; protect the airway and recheck glucose. |
| What are hallmark findings of diabetic ketoacidosis? | Hyperglycemia, ketones, metabolic acidosis, dehydration, abdominal pain, vomiting, and Kussmaul respirations. |
| What is the first major treatment priority? | Isotonic IV fluid resuscitation, followed by insulin and electrolyte management according to protocol. |
| Why must potassium be monitored closely during insulin treatment? | Serum potassium may fall rapidly as insulin moves potassium into cells. |
| What complication from overly rapid treatment is especially concerning in children? | Cerebral edema. |
| What findings suggest hyperthyroidism? | Weight loss, heat intolerance, tachycardia, tremor, anxiety, diarrhea, and increased metabolism. |
| What findings suggest hypothyroidism? | Weight gain, cold intolerance, bradycardia, fatigue, constipation, dry skin, and slowed thinking. |
| What findings suggest thyroid storm? | High fever, severe tachycardia or dysrhythmia, agitation or delirium, heart failure, and GI symptoms. |
| What findings suggest myxedema coma? | Severe hypothermia, bradycardia, hypotension, hypoventilation, hyponatremia, and decreased consciousness. |
| What are hallmark findings of SIADH? | Water retention, dilutional hyponatremia, low serum osmolality, concentrated urine, and low urine output. |
| What are hallmark findings of diabetes insipidus? | Large amounts of dilute urine, intense thirst, dehydration, hypernatremia, high serum osmolality, and low urine specific gravity. |
| How do urine patterns differ in SIADH and DI? | SIADH produces low-volume concentrated urine; DI produces high-volume dilute urine. |
| What findings suggest adrenal insufficiency? | Fatigue, weight loss, hypotension, hyponatremia, hyperkalemia, hypoglycemia, and hyperpigmentation in primary disease. |
| What are priority treatments? | Rapid IV fluids, IV glucocorticoids, correction of glucose/electrolytes, and treatment of the trigger. |
| What findings suggest excess cortisol? | Central obesity, moon face, thin limbs, purple striae, fragile skin, hypertension, hyperglycemia, infection risk, and osteoporosis. |
| Why should long-term corticosteroids not be stopped abruptly? | Abrupt withdrawal can precipitate adrenal insufficiency or crisis; taper only as prescribed. |
| What complications are associated with immobility? | Atelectasis, pneumonia, DVT, pressure injury, constipation, urinary stasis, contractures, and deconditioning. |
| What interventions reduce immobility complications? | Repositioning, skin care, ROM, early mobility, pulmonary hygiene, hydration/nutrition, and prescribed DVT prophylaxis. |
| What teaching supports bone health? | Weight-bearing and resistance exercise, adequate calcium/vitamin D, fall prevention, smoking cessation, and prescribed therapy. |
| What findings are typical of osteoarthritis? | Pain worse with activity, brief morning stiffness, crepitus, decreased ROM, and bony enlargement. |
| What are the six Ps of neurovascular compromise? | Pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia; severe pain and paresthesia may occur early. |
| What is the earliest concerning sign of compartment syndrome? | Severe pain out of proportion, especially pain with passive stretch, followed by paresthesia and tense swelling. |
| What is the priority response? | Notify the surgeon immediately, maintain the limb near heart level, loosen restrictive items as directed, and prepare for fasciotomy. |
| What findings suggest fat embolism syndrome after a long-bone fracture? | Respiratory distress, neurologic changes, fever, tachycardia, and a petechial rash. |
| What should a client report after cast placement? | Increasing pain, numbness, tingling, coolness, color change, swelling, inability to move digits, drainage, odor, or hot spots. |
| How is phantom limb pain managed? | Treat it as real pain using prescribed multimodal therapy; do not dismiss the client’s report. |
| What positioning helps prevent hip flexion contracture after lower-limb amputation? | Avoid prolonged hip flexion; use prescribed prone positioning and ROM when appropriate. |
| What is the first priority with a high cervical spinal cord injury? | Airway and breathing because diaphragmatic and respiratory-muscle function may be impaired. |
| What findings occur in spinal shock? | Temporary flaccid paralysis, absent reflexes, loss of sensation, and autonomic dysfunction below the injury. |
| What pattern suggests neurogenic shock? | Hypotension with bradycardia and warm, dry skin from loss of sympathetic tone. |
| Who is at risk for autonomic dysreflexia? | Clients with spinal cord injury usually at or above T6 after spinal shock resolves. |
| What findings suggest autonomic dysreflexia? | Sudden severe hypertension, pounding headache, bradycardia, flushing or sweating above the lesion, and cool pale skin below. |
| What is the first action for autonomic dysreflexia? | Sit the client upright, loosen clothing, check the bladder and bowel for triggers, and treat blood pressure as prescribed. |
| What are common motor findings in Parkinson disease? | Resting tremor, rigidity, bradykinesia, shuffling gait, postural instability, and reduced facial expression. |
| What are priority safety concerns? | Falls, aspiration, medication timing, orthostatic hypotension, constipation, and impaired communication. |
| Why must levodopa/carbidopa be given on schedule? | Delayed or missed doses can sharply worsen mobility and swallowing. |
| What is the first priority in a major burn? | Airway assessment, especially with facial burns, soot, hoarseness, stridor, or enclosed-space exposure. |
| What does an elevated carboxyhemoglobin indicate? | Carbon monoxide exposure; pulse oximetry may appear falsely reassuring. |
| What is monitored during initial fluid resuscitation? | Urine output, hemodynamics, mental status, peripheral perfusion, electrolytes, and response to the prescribed formula. |
| What finding suggests circumferential burn compromise? | Decreasing pulses or perfusion, increasing pain, neurologic changes, or impaired chest expansion. |
| What should the nurse do during a seizure? | Protect from injury, lower to a safe surface, turn to the side if possible, support the airway, time the seizure, and do not restrain or place objects in the mouth. |
| What is the priority after a seizure? | Airway and breathing assessment, side positioning, oxygen/suction as needed, neurologic reassessment, glucose check, and documentation. |
| What is status epilepticus? | A prolonged seizure or repeated seizures without recovery; it is a medical emergency requiring rapid medication and airway support. |
| What is the priority assessment for a client with depression? | Directly assess suicidal thoughts, plan, means, intent, prior attempts, protective factors, and immediate safety. |
| Why can suicide risk increase when energy begins to improve? | The client may gain enough energy to act before hopelessness has resolved. |
| What communication is therapeutic? | Use calm, open-ended statements, acknowledge feelings, allow silence, and avoid false reassurance or “why” questions. |
| How does postpartum depression differ from postpartum blues? | Depression is more persistent and impairing, may include hopelessness or thoughts of harm, and requires prompt evaluation. |
| What is the nursing priority during severe anxiety or panic? | Stay with the client, reduce stimuli, use short simple statements, guide slow breathing, and address immediate safety. |
| When should teaching occur during anxiety? | After anxiety has decreased enough for the client to process information. |
| What information is essential when assessing withdrawal risk? | Time and amount of last alcohol use, prior withdrawal seizures or delirium tremens, vital signs, current symptoms, and other substances. |
| What findings suggest severe withdrawal or delirium tremens? | Severe autonomic hyperactivity, agitation, hallucinations, confusion, fever, hypertension, tachycardia, and seizures. |
| What medication class is first-line for significant alcohol withdrawal? | Benzodiazepines, titrated according to protocol and symptoms. |
| Why is thiamine given? | To reduce risk of Wernicke encephalopathy; it is commonly given before or with glucose in at-risk clients. |
| What distinguishes delirium from dementia? | Delirium has acute onset, fluctuating attention and awareness, and is often reversible when the cause is treated. |
| What pattern is typical of dementia? | Gradual progressive decline in memory and cognition with relatively stable alertness until later stages. |
| What is the priority approach to delirium? | Identify and treat the cause, protect safety, provide calm reorientation, support sleep and sensory aids, and avoid unnecessary restraints. |
| How should the nurse respond to a delusion? | Acknowledge the client’s feelings, state reality briefly, and redirect without arguing or validating the false belief. |
| What must be assessed with command hallucinations? | Exactly what the voices say, whether they direct harm, the client’s intent and ability to resist, and immediate safety. |
| What findings suggest neuroleptic malignant syndrome? instability; stop the drug and obtain emergency treatment. | High fever, severe rigidity, altered mental status, and autonomic |
| What findings suggest tardive dyskinesia? chewing, or limb/trunk movements. | Involuntary repetitive movements, especially lip smacking, tongue movements, |
| What boundaries are therapeutic with manipulative behavior? | Clear, consistent, neutral limits applied by the entire team without bargaining or punitive responses. |
| When is confidentiality overridden? | When required to protect the client or identifiable others from serious imminent harm, or as mandated by law and policy. |
| What is the least restrictive intervention principle? | Use the safest intervention that limits freedom the least; restraints and seclusion are last resorts with continuous reassessment. |
Created by:
Anmag002