NCLEX PREP QUESTIONS ALL QUESTIONS AID GRADE A+ SOLUTION 100% CORRECT

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The nurse receives report on 4 clients. Which client should the nurse see first? 1. Client admitted 12 hours ago with acute asthma exacerbation who needs a dose of IV methylprednisolone [21%] 2. C... lient admitted 2 days ago with congestive heart failure who is reporting shortness of breath and had an extra dose of furosemide prescribed recently [55%] 3. Client admitted with intestinal obstruction who is reporting abdominal pain and distention and needs nasogastric tube placement [17%] 4. Client who had cardiac valve surgery 8 days ago but was readmitted with a sternal wound infection and needs antibiotics and a dressing change [6%] Although it is not a STAT order, an extra dose of furosemide was prescribed for the client with congestive heart failure. The shortness of breath is most likely due to a change in fluid status, and this client is the priority. Furosemide works immediately and should be given urgently. (Option 1) Even though this client has asthma exacerbation, steroids (methylprednisolone [Solu-Medrol]) do not show their effect immediately. These drugs control underlying inflammation but take several hours/days to take effect. Bronchodilators such as albuterol or ipratropium work immediately. Educational objective: A client who is experiencing symptoms that could compromise airway, breathing, or circulation should be seen first. What works immediately ASTHMA work immediately ASTHMABronchodilators such as albuterol or ipratropium A 59-year-old client comes to the clinic due to a blistering, linear rash on the left chest. The client reports itching and pain around the rash. What is the priority question for the nurse to ask the client? 1. "Did the rash start after taking a new medication?" 2. "Have you been keeping the rash covered?" 3. " 4. "What have you tried to help the pain?" Correct Answered correctly Have you ever had chickenpox?" {NI} f this rash is determined to be due to shingles, the affected area should be covered to prevent the spread of infection. Therefore, it is a priority to ask if this client has had chickenpox. AIRBORN ISOLATION N-95 can occur in clients with a history of chickenpox (varicella-zoster virus exposure). The vesicular rash has a characteristic, linear dermatomal distribution and can present with severe pain. Vaccination prevents shingles. Herpes zoster (shingles) CDC& Prevention recommends shingle vaccine for use in people 60 years old and older to prevent shingles Why should nurse anticipate the health care provider transferring to the intensive care unit? 82-year-old with pressure (decubitus) ulcer who has a change in mental status, temperature of 96.4 F (35.8 C), pulse of 110/min, and blood pressure of 96/72 mm Hg [69%] Sepsis is a potentially life-threatening condition. Physiologic changes related to the aging process, including decreased immune function and inflammatory response (immunosenescence) and altered febrile response to pyrogens, increase the risk for sepsis. can be the presenting feature of sepsis in elderly clients. Hypothermia abnormally high levels of nitrogen-containing compounds azotemia 60-year-old with chronic kidney disease who has a blood pressure of 168/88 mm Hg, serum creatinine level of 5.0 mg/dL (442 µmol/L), and reports nausea and itching [15%] EXPECTED Hypertension, elevated serum creatinine level (normal: 0.6-1.3 mg/dL [53-115 µmol/L]), nausea associated with azotemia, and pruritus associated with dry skin are expected for chronic kidney disease clients. early recognition of sepsis is critical to survival, atypical presentation associated with immunosenescence and absence of fever can delay diagnosis and treatment. early sepsis Systemic inflammatory response syndrome Finding Value Temperature >100.4 °F or <96.8 °F Heart rate >90/min Respiratory rate >20/min or PaCO2<32 mmHg (4.3 kPa) WBC <4000/mm³, >12x109/L (>12,000/mm³), or 10% ban The influenza virus has an incubation period of 1-4 days, with peak transmission starting at about 1 day before symptoms appear and lasting up to 5-7 days after the illness stage begins Influenza is transmitted by inhaling droplets that an infected individual exhales into the air when sneezing, coughing, or speaking vaccination provides immunity against influenza in about 2 weeks after inoculation, it does not offer complete protection against all virus strains. Therefore, close contact with others should be avoided during the illness stage, especially those with an impaired immune system. Influenza is a highly contagious respiratory infection transmitted by airborne droplets and direct contact. It has an incubation period of 1-4 days, with peak transmission starting at about 1 day before symptoms appear and lasting up to 5-7 days after the illness stage begins. Vaccination does not offer complete protection against all virus strains. Femoral-popliteal bypass surgery involves circumventing a blockage in the femoral artery with a synthetic or autogenous (artery or vein) graft to restore blood flow. Femoral-popliteal bypass surgery[NI] The nurse performs neurovascular assessments on the affected extremity (ie, pulses, color and skin temperature, capillary refill, pain, movement) and compares the findings with the preoperative baselinen. on palpable pedal pulse that is present only with Doppler distal to the graft (ie, post-tibial, pedal) can indicate compromised blood flow or graft occlusion and should be reported to the health care provider immediately!!!!! the inability of the leg veins to efficiently pump blood back to the heart. It can lead to venous stasis, increased hydrostatic pressure, and venous leg ulcers. Edema and thick skin with brown pigmentation are expected manifestations Chronic venous insufficiency Gangrene of the foot is a complication of associated with decreased blood flow to the extremity. peripheral arterial disease (PAD) expected manifestations of PAD Coolness of the skin and shiny, hairless legs, feet, and toes Intermittent claudication is leg pain caused by decreased blood flow to the muscles that reoccurs during activity such as walking and dissipates with rest. expected Intermittent claudication Absent or decreased volume in the peripheral pulses distal to the graft can indicate compromised circulation or graft occlusion and should be reported to the health care provider immediately!!!!! ABC! percutaneous endoscopic gastrostomy (PEG) tube a minimally invasive procedure performed under conscious sedation. Using endoscopy, a gastrostomy tube is inserted through the esophagus into the stomach and then pulled through an incision made in the abdominal wall. To keep it secured, the PEG tube has an outer bumper and an inner balloon or bumper. The PEG tube's tract begins to mature It begins to close within hours of tube dislodgement. The nurse should notify the health care provider who placed the PEG tube as early dislodgement (ie, <7 days from placement) requires either surgical or endoscopic replacement 1-2 weeks and is not fully established until 4-6 weeks IF dislodgement, the nurse should notify the health care provider who placed the PEG tube as early dislodgement (ie, <7 days from placement) requires either surgical or endoscopic replacement DO NOT: Attemptto reinsert a tube through an immature tract can result in improper placement into the peritoneal cavity, leading to peritonitis and sepsis!!!!!!! The client is exhibiting signs and symptoms OF fever, chills, nausea ,subnormal body temperature instead of fever, hypotension, tachycardia, decreased urine output, and confusion The client is exhibiting signs and symptoms of septicemia (blood infection) CVCs are warranted to provide important treatment for many clients, they are often a source of infection that can lead to sepsis and septic shock In addition to obtaining blood cultures x 2, it is standard procedure to cut off the tip of the discontinued CVC and send it to the lab to ensure it is the source of the septicemia Ondansetron may be administered for nausea symptoms. When signs of infection or sepsis occur, the nurse should obtain cultures prior to antibiotic administration. Identification of the specific pathogen helps the HCP determine the best antibiotic for treatment. If the culture is obtained after antibiotic administration, the culture results will be altered. Mantoux test, is administered to screen for tuberculosis (TB). The forearm is injected with 0.1 mL of the PPD, and the client returns in 48-72 hours to have the site assessed for induration (a raised area). Redness alone is not read as a positive response. An area of induration >15 mm is considered a positive response in any client (Option 1). However, a positive PPD test does not mean that the client has active TB infection but rather that the client has been exposed to TB and has developed an immune response. Positive sputum cultures, chest x-rays, and the presence of symptoms confirm that the client has active disease TB Sjögren's syndrome is an autoimmune condition. It causes inflammation of the exocrine glands (eg, lacrimal, salivary), resulting in decreased production of tears and saliva and leading to dry eyes (xerophthalmia) and dry mouth (xerostomia). Sjögren's syndrome NI Treatment with over-the-counter, preservative-free artificial tears can relieve eye dryness, burning, itching, irritation, pain, and a gritty sensation in the eyes. Wearing goggles can protect the eyes from outdoor wind and dust. Dry mouth is treated with artificial saliva. Using a room humidifier and not sitting in front of fans and air vents can also help Early-morning low back stiffness is seen ankylosing spondylitis Multiple tender points are characteristic fibromyalgia Thickening of the skin scleroderma Sjögren's syndrome is an autoimmune condition that can cause dry eyes and mouth Clients are instructed to use artificial tears and saliva. Vancomycin is a glycopeptide antibiotic that is excreted by the kidneys. It is used to treat serious infections with gram-positive microorganisms (Staphylococcus aureus [methicillin-resistant Staphylococcus aureus]) and diarrhea associated with Clostridium difficile. Serum vancomycin trough level is monitored before the 4th dose (15-20 mg/L [10.4-13.8 µmol/L] is optimal) OF Vancomycin Blood urea nitrogen (BUN) and creatinine levels are monitored regularly (usually 2-3 times/week) in clients receiving the drug due to increased risk of nephrotoxicity, and ototoxicity especially in those with impaired renal function, receiving aminoglycosides, and who are >60 years old Before administering this VANCOMYCIN, the nurse should The normal range for BUN is 6-20 mg/dL (2.1- 7.1 mmol/L) and creatinine is 0.6-1.3 mg/dL (53-115 µmol/L). notify the HCP that the client's BUN and creatinine are increased. A normal hemoglobin level of in adult men; 13.2-17.3 g/dL A normal hemoglobin level adult women 11.7-15.5 g/dL magnesium level 1.5-2.5 an overproduction of collagen that causes tightening and hardening of the skin and connective tissue. Scleroderma This is a progressive disease without a cure RN T= treatment is aimed at managing complications in Scleroderma Renal crisis is a life-threatening complication that causes malignant hypertension due to narrowing of the vessels that provide blood to the kidneys. Early recognition and treatment of renal crisis is needed to prevent acute organ failure. Even with treatment, this can be fatal. Raynaud phenomenon can develop secondary to scleroderma vasospasm-induced color changes in the fingers, toes, ears, and nose. This requires urgent treatment (eg, immersing hands in warm water) but is not life-threatening. Raynaud phenomenon Pulmonary fibrosis is a progressive complication of that is defined as scarring of lung tissue, which then causes reduced function, dry cough, and dyspnea. Some clients may be placed on oxygen. This is not immediately life-threatening. scleroderma Heartburn and dysphagia (difficulty swallowing) are common symptoms associated with scleroderma is caused by collagen overproduction; it is a lifelong disease without a cure. Treatment is aimed at controlling symptoms and preventing further complications. Renal crisis is life-threatening and should be recognized and treated immediately. Scleroderma Acute cholecystitis Expected S/S NI The client is scheduled for surgery and is likely on antibiotics. Even if the client is not on antibiotics, neutropenia is a priority over acute cholecystitis inflammation of the gallbladder s/s upper quadrant pain that can radiate to the right shoulder, nausea, vomiting, fever, and leukocytosis NI:The client is scheduled for surgery and is likely on antibiotics is a malignant cancer of the lymphatic system? Expected Early S/S Hodgkin lymphoma S/S: include painless enlarged lymph nodes, fatigue, fever, weight loss, and drenching night sweats. is a toxin-producing bacterium that proliferates in the lower gastrointestinal tract. Expected s/s include diarrhea, fever, and leukocytosis. First-line treatment metronidazole (Flagyl) and oral vancomycin. Clostridium difficile s/s include diarrhea, fever, and leukocytosis. TX: metronidazole (Flagyl) and oral vancomycin contact isolation Use soap and H2o Common adverse effects of chemotherapy are bone marrow suppression (eg, anemia, leukopenia, thrombocytopenia) and immunosuppression. Even a low-grade fever should be taken seriously in clients who are immunosuppressed or have neutropenia Isotonic IV solutions (eg, 0.9% sodium chloride, lactated Ringer's) have the same osmolality as plasma and are administered to expand intravascular fluid volume. TX: vomiting and diarrhea, burns, and traumatic injury. Anaphylaxis causes increased capillary permeability, leaking intravascular fluid into free spaces; this places the client at risk for hypotension. TX? Isotonic IV solutions (eg, 0.9% sodium chloride, lactated Ringer's) hyperglycemia / diabetic ketoacidosis results in osmotic diuresis and dehydration. TX: immediate initial treatment is IV fluid resuscitation with isotonic 0.9% sodium chloride to replace fluid losses, stabilize vital signs, reestablish urine output, and dilute the serum glucose concentration before initiating insulin therapy. Should you use hypotonic IV solution (ie, 0.45% sodium chloride) to replace gastrointestinal tract fluid losses ? NO! I will make fluid volume deficit worse. TX: Isotonic 0.9 sc LR A client with head trauma is at risk for increased intracranial pressure due to inflammation and cerebral edema IV mannitol is an osmotic diuretic that reduces cerebral edema by pulling water from the cerebral cells into the vasculature Priapism The nurse should return this call first as the condition is a prolonged, painful erection (>2 hours) caused by trapping of blood in the penile vasculature that can lead to erectile tissue hypoxia and necrosis. The condition is usually idiopathic, secondary to prescription medications (eg, sildenafil, trazodone) or a preexisting medical condition (eg, sickle cell disease, cocaine use). Priapism EMERGENCY that can result in permanent erectile dysfunction; it requires urgent treatment in the emergency department. PRIAPISM >2HRS streptococcal pharyngitis complication 2-3 weeks after. RF (rheumatic fever) is an acute inflammatory disease of the heart The nurse should ask about a streptococcal throat infection when collecting health history information in a client suspected of having RF. descending flaccid paralysis (starting from the face), dysphagia, and constipation (smooth muscle paralysis). Botulism (The main source is improperly canned or stored food) Children under age 1 year should not be given honey b/c their immature gut system makes them prone to developing infant botulism. an autoimmune disorder in which an abnormal immune response leads to chronic inflammation of different parts of the body. Ranges in severity from mild: eg, affecting skin, muscles, joints to severe: eg, affecting kidneys, heart, lung, blood vessels, central nervous system) disease. I Systemic lupus erythematosus (SLE) creatinine normal 0.6-1.3 mg/dL blood urea nitrogen normal 6-20 mg/dL 6-20 mg/dL potentially serious complication of SLE lupus nephritis (occurring in 50%) NI: Early recognition and aggressive immunosuppressive treatment are essential to preserve renal function and prevent irreversible kidney damage diagnosed with SLE positive antinuclear antibody (ANA) titer (>1:40) indicates the presence of ANAs, which the body produces against it own DNA and nuclear material often present in SLE Anemia, mild leukopenia (white blood cell count <4,000/mm3 [4.0×109/L]), and thrombocytopenia (platelet count <150,000/mm3 [150×109/L]) A pt with SLE has Anemia, mild leukopenia, thrombocytopenia, Lupus nephritis, which is the GREATEST CONCERN? Increased serum creatinine >1.3 mg/dL, increased blood urea nitrogen >20 mg/dL, and an abnormal urinalysis can indicate the presence of LUPUS NEPHRITIS potentially serious complication of SLE in which inflammation of the kidney can lead to renal injury. Early recognition and treatment are essential to preserve renal function and prevent irreversible kidney damage. Tuberculosis is an infection caused by the the Mycobacterium tuberculosis microorganism A client with active, primary TB disease has a positive tuberculin skin test (TST), usually feels sick, has symptoms, and can spread the disease to others if not treated with medications. A client with a LATENT TB infection (LTBI) has a positive TST, negative chest x-ray, is asymptomatic, CANNOT transmit the disease to others, and can complete a full course of treatment to prevent activation of the disease. A pt. who has Malignancy, immunosuppressant medications, including chemotherapy, and prolonged debilitating disease (eg, HIV), is at RISK convert LATENT TB infection to active disease A client with LTBI who begins treatment with a corticosteroid (Prednisone) is at increased risk for conversion to active TB disease. Therefore, the nurse should recognize this and: notify the HCP. is a proton pump inhibitor used to treat ulcer disease, erosive esophagitis, and gastroesophageal reflux disease. Lansoprazole (Prevacid) is an antimicrobial medication used to treat IBD and does not convert LTBI to active disease. Metronidazole (Flagyl) is a gastrointestinal anti-inflammatory medication used to treat IBD Sulfasalazine (Azulfidine) West Nile virus is transmitted by an infected mosquito bite. RN TEACH: avoiding mosquitoes USE a mosquito repellent. Prevention also includes keeping arms and legs covered with light-colored clothing and avoiding outdoor activities at dawn and dusk. Sodium polystyrene sulfonate (Kayexalate) is used to treat mild to moderate hyperkalemia. Potassium is exchanged for sodium in the intestines and excreted in the stool, thereby lowering the serum potassium. During sodium polystyrene sulfonate therapy, severe hypokalemia (palpitations, lethargy, cramping) can develop. RN will need to MONITOR Frequent electrolyte status Because potassium exchanges with sodium content of the resin, excess sodium absorption could put clients at risk of developing volume overload (water follows sodium). fluid overload (eg, crackles, jugular venous distension, edema) and have daily weights and intake and output assessment bedside commode frequent stools watch skin intergerty Clients receiving sodium polystyrene sulfonate must have normal bowel function to avoid the risk of intestinal necrosis. The nurse must assess for constipation, signs of impaction, and recent bowel patterns. ANY Postoperative clients are at an increased risk for vomit aspiration due to nausea and an altered level of consciousness (caused by anesthesia) RN recognizes: ABC These clients should be placed on their side and should receive antiemetics to prevent potential airway and breathing complications After transurethral resection of the prostate RN EXPECTS: continuous bladder irrigation for 24-36 hours flushes out small clots and prevents obstruction. Reddish- pink drainage is expected in the immediate postoperative period. Immediate postoperative nursing care focuses on management of the airway, breathing, circulation, bleeding, and pain. ******The same frameworks that guide nurses to prioritize nursing care can guide them to prioritize returning client phone calls as well. These include (in order)******* Maslow's hierarchy of needs; and airway, breathing, cardiac status, circulation, and vital signs (ABC plus V). EXPECTED common side effects within 24 hours after receiving the influenza vaccine low-grade temperature, myalgia, headache, congestion, pain, redness, and itching at the injection site are common expected side effect after use of a short-acting beta-agonist metered-dose inhaler. Palpitations Urinary tract infections (UTIs) are (Options 1 and 2) When the infection ascends to the kidneys (pyelonephritis), clients become very ill. They develop nausea, vomiting, fever with chills, and flank pain. Assessment shows costovertebral angle tenderness. If the infection is not recognized and treated, clients can become septic. Educational objective: Cystitis is an infection of the bladder mucosa. Clients develop burning with urination (dysuria), urinary frequency and urgency, hematuria, and suprapubic discomfort. However, if the infection extends to the kidneys (pyelonephritis), clients become seriously ill with nausea, vomiting, fever with chills, and flank pain. usually bacterial in origin and are most often caused by Escherichia coli cystitis is the most common community-acquired UTI. It is an infection of the lower urinary tract and involves inflammation of the bladder mucosa, leading to hyperemia, tissue hemorrhage, and pus formation. This inflammatory process leads to burning with urination (dysuria), urinary frequency and urgency, hematuria, and suprapubic discomfort ( pyelonephritis bacteria may continue to ascend the urinary tract to the ureters and kidneys, causing inflammation and infection in the kidneys cystis Expected S/S hyperemia tissue hemorrhage pus formation This inflammatory process leads to burnin [Show More]

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