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NCLEX 2012 Review
Questions to help prepare
| Question | Answer |
|---|---|
| Hypertension, what lifestyle modifications should be implemented? | Limit alcohol, exercise regularly, reduce sodium intake, and stop smoking. |
| After an abdominal aortic aneurysm resection what is a priority assessment? | Urine output |
| What would indicate pulmonary edema is improving? | No adventitious lung sounds |
| Coronary artery bypass, what medication is important to stop one week prior? | Coumadin |
| Stress test for 11 a.m., should it be rescheduled if patient smoked this morning? | Yes |
| Digoxin and Lasix, what adverse reaction can occur? | Light-headedness, due to possible hypotension |
| Aortic aneurysm repair, what might indicate shock? | Urine output of 20 ml |
| What is a complication with endocarditis? | Valvular disease |
| True or false: Hiccups are a sign of complication after a pacemaker placement? | True |
| True or false: You must rotate nitroglycerin topical patch sites? | True |
| If a patient is receiving heparin IV for DVT and has an aPTT value of 96 seconds what would you do? | Stop infusion immediately |
| What difference sign may or may not be present in a patient with an arterial venous leg ulcer? | Claudication |
| What sided heart failure is manifested by weak peripheral pulses, right or left? | Left-sided heart failure |
| What is a lab level of an increase in creatinine kinase indicative of? | MI/Heart attach |
| What would it indicate if a patient has increased difficulty after a 1 mile walk? patient who has dilated cardiomyopathy | Left Ventricular Failure |
| A patient who is recovering from a CABG and has a B/P of 140/82 on inspiration, and a B/P of 154/90 on expiration indicate? | Cardiac Temponade |
| What is one of the biggest disease risk factors for peripheral artery disease? | Diabetes |
| True or false: A patient who is on Coumadin for DVT is at a therapeutic range with a INR of 2.5? | True |
| What would a patient with heart failure and atrial fib who develops slurred speech indicate? | Possible emboli |
| What intervention should the nurse perform first (other than calling MD)if a new patient has a hypertensive crisis and develops a B/P of 254/139? | Initiate IV |
| True or False: Thrombolytic therapy is contraindicated in a patient who is 1 week S/P surgery for an MI? | True |
| True or False: A patient who is on an ACE Inhibitor should notify the doctor if a persistent cough develops? | True |
| What allergy is essential to ask about when a patient is to undergo a coronary angiography? | Shell fish allergy |
| True or False: A patient who has a heart transplant, may not be able to feel chest pain any longer? | True |
| EKG/ECG shows 70 complexes/min, PR interval 0.16, QRS measures 0.16 sec, PR interval slightly irregular, what cardiac rhythm would this be? | Sinus dysrhythmia |
| What sided failure is would jugular vein distension and dependent edema be indicative of? | Right-sided heart failure |
| What sided CVA would be manifested by visual spatial deficits, left hemianopsia, and one-sided neglect? | Right CVA |
| What is the highest priority in monitoring a patient with hear failure receiving a blood transfusion? | Lung sounds, for crackles in the lungs |
| What is a priority to monitor for after a patient has had a CVA/stroke? | Dysphagia |
| What sign would indicate a CVA/stroke victim is suffering from homonymous hemianopsia? | Patient turns head to view visual field |
| What reflex is most important to check for on a patient who had a left-sided CVA/stroke? | Gag-relfex |
| How many minutes do you hold pressure after drawing ABGs on a patient who has a continuous drip of heparin infusing? | 20 minutes (5 minutes if not on anticoagulants) |
| What is a common side-effect of Glucophage to watch for? | GI disturbances |
| A patient who cannot communicate what would indicate that the patient needs pain medication? | Increase in heart rate, increased respirations, restlessness, and increase blood pressure. |
| A patient with liver cirrhosis what would you implement to prevent esophageal varicies? | Stool softner |
| Hyperkalemia would show up how on an EKG/ECG? | Tented T-waves |
| What is important for a nurse to incorporate in the plan of care after a bronchoscopy? | Keep patient NPO until cough reflex returns |
| Heat stroke patient what should nurse implement first? | Cooled normal saline IV |
| Inderal is contraindicated with what disease? | Asthma patient |
| If you run out of TPN what action should the nurse take? | Run dextrose 10% in water until TPN is available. |
| Patients on coumadin should avoid what medications? | Aspirin, barbiturates, ginger, ginseng, and oral contraceptives...to name a few. |
| Does constant bubbling in a closed water-seal drain system require immediate action? | Yes, it indicates an air leak |
| Laryngectomy a nursing priority with nursing care is? | Increase in mucus production |
| What explanation should a nurse give a patient about their Type 2 diabetes? | Their pancreas is working, but not producing enough insulin. |
| What type of seizure is indicated by an aura prior? | Partial seizure |
| Should a patient who is receiving TPN increase their TPN rate on days that they have increased exercise? | No |
| What indicates server airflow obstruction in a patient who has a history of asthma and has pneumonia? | Silent chest |
| Patient who has extreme shortness of breath and an inability to lie down, and is using accessory muscles to breath, and still has hypoxia on 100% O2 what would you suspect? | ARDS Acute Respiratory Distress Syndrome. |
| Patient with a potassium level of 6.5, what EKG changes could you expect? | Peaked T-waves |
| In respiratory acidosis what causes acid/base imbalance? | Retension of carbon dioxide. |
| Should patient on Synthroid notify their doctor if their heart rate is racing? | Yes, this is an adverse effect |
| What other complication or disease would you suspect of a patient who has Cushings disease and has been on long-term use of corticosteroids? | Osteoporosis |
| What should nurse recommend to a patient who is on cogentin and has dry mouth? | Brush teeth regularly |
| How do you care for pins on a patient on skeletal traction? | Rinse pin sites with sterile saline |
| What is a nursing priority with a patient who has systemic lupus erythematous (SLE)? | Patient's fatigue |
| What should the nurse tell to a patient who has nephrotic syndrome, who asks what causes the edema? | The loss of protein in the urine causes edema |
| What test would indicate that the Lactated Ringers solution has been effective in replacing the NG output? | Urine specific gravity at 1.020 |
| Should the nurse report cloudy dialysate drainage in a patient who is receiving peritoneal dialysis? | Yes, it indicates that the patient could have inflammation of the peritoneum. |
| What should the nurse watch for in a patient receiving Kenalog? | Thinning of skin |
| What is the main symptom of hypovolemia? | Increased rapid pulse |
| Respiratory Alkalosis is indicated by? | Decrease in PaCO2, and PCO2 and SaO2 at hypoxic levels, and Ph is alkaline. |
| What other effect would be likely in a patient's labs with hypernatremia (high sodium blood level)? | Decrease in serum osmolarity |
| With Coumadin what effect should be reported by the patient to the doctor if it occurs? | Confusion |
| What is the goal of a patient who has had a knee arthroplasty upon discharge? | 90 Degree bending of the knee |
| What position should the nurse put a patient who has a central venous catheter pull out of a subclavian vein? | Left side in Trandelenburg position |
| How long should a women sustain from having intercourse after undergoing loop electrosurgical excision for cervical cancer? | 3 weeks or until her doctors okays it |
| What would help prevent intracranial pressure in a patient with a head injury? | Elevate the head of bed 30 Degrees |
| What position do you want the paitent's leg to be in after a hip arthroplasty surgical intervention? | Avoid position of adduction, no inward rotation of the surgical leg. (Abduction is acceptable) |
| What is an adverse eye effect of a patient who has TB and is receiving Ethambutol? | Optic neuritis |
| If a patient suffered a basilar skull fracture and is experiencing serosanginous nasal drainage, how would you test this? | Look for halo sign, by collecting nasal drainage on a dressing and watch for yellowish ring to form. |
| What action should the nurse take if she has a patient who is AB positive and she notices the blood that is infusing is B negative blood? | It's okay, just monitor for adverse reaction |
| What stage of ulcer would be one that has a shallow crater that involves the epidermis? | Stage II ulcer |
| What should the nurse implement for a paitent who is experiencing atelectasis after cardiac surgery? | Preform incentive spirometry every 2 hours |
| Where would you check for Murphy's sign in a patient who is experiencing abdominal pain to rule out appendicitis? | Right upper quadrant of abdomen |
| What blood pressure change would indicate a concern in a patient with a traumatic brain injury? | Widening pulse pressures (for example: having B/P go from 130/80 to 150/50) |
| What should the precaution should the nurse implement with a patient with bacterial meningitis? | Wearing a surgical mask |
| If a patient in the PACU has a systolic B/P of 88 and their baseline B/P was from 124-130 what nursing action should the nurse take? | Administer O2 and lie the patient flat |
| What eye condition would be the result of microvascular compromise in a patient with Type 2 diabetes? | Retinopathy |
| What supplement should be initiated for a patient with chronic renal failure? | Folic acid |
| How many ml of blood should be discarded from a central venous catheter to have accurate results of a blood specimen collected? | 5-10 mls |
| What are 3 things that should be included in caring for a client after they have a transurethral resection of the prostate? | Reposition frequently, monitor temperature every 4 hours, and apply warm compresses to manage bladder spasms. |
| PICC line care should include: | Assess site every 8 hours, flush with 10 cc, change dressing every 7 days (unless otherwise indicated) |
| What diet change can a patient with COPD implement in their self-care to better control their disease? | A diet low in carbohydrates (a high carb diet causes an increase in carbon dioxide) |
| What kind of stroke would be manifested by a sudden headache, decrease level of consciousness, and hypertension? | Hemorrhagic stroke (caused by bleeding into the brain) |
| With Myasthenia Gravis you would expect the patient to exhibit muscle weakness that improves with rest and what other issue? | Ptosis (dropping eye-lid) |
| What would these finding indicate: Ph 7.48, HCO3 24, SaO2 85%, PCO2 30, PO2 55, and the patient is anxious and has tingling lips and fingers? | Respiratory alkalosis |
Created by:
rebander
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