The following possible best answers are based on the information found in nursing textbooks, and the underlying principle for safe and effective care that NCLEX is testing for. 1. Alzheimer's patient incontinent of urine during the night times. The nursing care includes a) Offers bed pan every 2 hours-NO, would be appropriate to bring the client to the toilet or commode every 2 hours during the day, but this action means you disturb the client's sleep. b) Limit fluids during evening times, BEST ANSWER-(Source: Black & Hawks, Medical-Surgical Nursing 7th edition) Specific interventions for the Alzheirmer's client with urinary incontinence: "Sometimes the client forgets where the bathroom is located. Having bright lights and frequently taking the client there may help control incontinence. Fluid intake after the dinner meal can be restricted to maintain continence during the night." c) Foley's catheter-NO, would increase risk of lower urinary tract infection, inappropriate and not necessary.
2. After immediate post operative hysterctomy patient to observe (or) Nursing care includes a) Observe vaginal bleeding b) Urine output c) Vital signs-BEST ANSWER, as this provides the best/most information about the client's response to surgery and anesthesia.
3. Dilantin prescribed to the patient, to instruct the patient that includes a) Reticulocyte counts-Yes, this will test for decreased reticulocyte count a sign that the patient is developing aplastic anemia, a potentially life threatening side effect of Dilantin therapy. b) Platelet counts-No, however Dilantin can decrease the platelet count and result in thrombocytopenia. Aplastic anemia is considered to be more serious (Davis Drug Guide) 4. On the ECG found a straight line, first Nurse a) Assess the patient-BEST ANSWER, always assess the patient to be sure there is no equipment malfunction, and/or to confirm the information on the monitor.
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c) IV fluids Cancel Download And Print 5. 15% superficial burns, 20% partial thickness burns. If the fluids adequate
a) Urine output 30-40ml/hr BEST ANSWER, the patient's fluid balance/hydration status is best evaluated by assessing urine output. Urine output should be between 0.5 and 1.0 mL/kg/hr, which for a 130 lb adult would be between 29.5 -59 mL/hr. Most nursing textbooks consider 30 mL/hr of urine output to indicate appropriate fluid balance/hydration. b) BP c) Vital signs d) Skin turgor For b, c, and d many other factors can affect these findings. Urine output directly correlates with the patient's hydration status/fluid balance. 6. 20 week pregnant most concerned A ) Butterfly rash on both cheeks and nose-NO this is Cholasma the "mask of pregancy", result of hormonal changes in pregnancy. b) Uterus palpate at the level of symphysis pubis-BEST ANSWER this correlates with 12 weeks gestation and the patient in the question is 20 weeks. This is a significant difference. c) Sereous fluid drain in the breasts-NO, leaking of clear fluid from the breasts during pregnancy is not unusual. d) Breast enlargement-NO, the breast enlarge during pregnancy. 7. The sterile technique is broke when a) The sterile field and supplies are wet-BEST ANSWER, this would allow microorganisms to enter the sterile field through the wet surface. b) Clean the area peripheral to center-NO, this is inappropriate technique but response a, specifically describes how a sterile field can be contaminated and is an important principle in maintaining sterile fields. 8. The metal piece is embedded on the left eye a) Pressure dressing is applied on the left eye-NO, this would "push" the object further into the eye. b) Dressing is applied on both eyes-BEST ANSWER, you want to keep the left eye still,
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c) Irrigate the eye with saline-NO, the object is embedded, meaning deep within the eye. Cancel Download And Print Irrigation will not remove the object but theoretically it could cause it to move resulting in further damage. 9. After cerebral angiogram, patient is a) Encourage fluids-BEST ANSWER, when ever contrast medium/X-ray dyes are administer the client is hydrated to facilitate excretion of the dye. b) obseve contrast medium in the urine-NO, should not be observable to patient or nurse. c) walking-NO, bedrest would be maintained for a prescribed period of time. 10. Using clean, non sterile gloves care is appropriate a) wash the genitelia........YES/NO- YES, this is not a sterile procedure.
Question:
A patient is receiving 1,000 ml of 5% glucose and 0.45% normal saline with 40 mEq of potassium chloride. most important for nurse to monitor the patient : A. pulse rate B. daily weight C. skin turgor Answer1: I would say, always check for urine output before commencing anything with Potassium because it can only be excreted in the urine. Hence if you are dehydrated & have decrease urine output & commenced on K+ hyperkalemia will arise leading to cardiac arrythmia. Answer2: The answer is pulse rate
Question:
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a. he is drinking from a ceramic pitcher. Download And Print Cancel b. father refurnishes old furniture at their home 2) a TB pt understands that he can reduce the risk of spreading his disease if he states? a. i wont sleep in same room w/ my wife for 1-2 months b. i will stay away from pregnant women a nd children c. i will use plastic utensil when i eat 3) 4 years old with salmonella what u should do? a. private room b. isolation c. place in a room with 4 year old with cellulitis d. keep door closed at all times. 4) wat herb would help with vomiting? a. ginkgo b. ginseng. c. ginger root d. echinacea 5) allergic to sulfa wat not to take? a. ma huang b. echinacea. 6) mother called a nurse from home stating that her child having chicken pox, which of the following statements by the mother needs immediate follow up? a. father of the child with liver failure b. sibling with anemia c. child just had tonsillectomy d. child has intermittent low grade fever 7) client with allergy to sudafed ..which of the statments is correct? a. i will take valerian b. i will take ma huang c. i will take echinacea for acute viral inf. d. i will take black cohosh
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a. frozen food can be defrost for up to six hours b. frozen food which has been Cancel defrost can Download be return back fridge. And to Print c. cook perishable food should cover and cool d. frozen food should be defrost by hot water 9) child in a mist tent and the parents brought him a car toy...the child was clutching the toy and the nurse refused to let him play for wat reason? a. it will get contaminated with bacteria b. it will accumalate moisture c. it could cause a fire 11) a mother reported that her son is throwing up each time she feeds him wat would be the best question u ask? a. did u warm up the formula b. wot kind of formula did u give him c. does ur son feel hungry each time he throws up d. does ur son have a jelly like stool 12) a patient had aids the nurse should advise? a. cook ur meat very well b. not to eat in the same table with family c. avoid crowds
Answer: 1)a young patient most likely to get lead poisining if? a. he is drinking from a ceramic pitcher. b. father refurbishes old furniture at their home
> ANSWER is B. probably if he refurbishes an old furniture at home.. that is, if the furniture has old paint on it and during 60's paints have lead content on it (heavy metals) and if you need to remove that, chips from the old paint may be taken by a kid that leads to Pb poisoning 2) a TB pt understands that he can reduce the risk of spreading his disease if he states? a. i wont sleep in same room w/ my wife for 1-2 months b. i will stay away from pregnant women a nd children
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****>> if the patient is already taking anti-TB drugs, it will only be 2 weeks of chemotherapy and that (+) PTB will no longer be communicable.. and 1-2 months is Cancel Download And Print long! CHildren are more susceptible to acquire Primary complex and pregnant women are susceptible and almost vulnerable to all type of illnesses.. There is no need for the patient to separate their utensils since PTB is airborne and not by contact in terms of transmission.. so i go for B answer. 3) 4 years old with salmonella what u should do? a. private room b. isolation c. place in a room with 4 year old with cellulitis d. keep door closed at all times. *** the (+) salmonella kid may be placed in a private room. Salmonella is transmitted by Enteric.. therefore Enteric precaution is needed and handwashing is very important and gown and gloves, diaper or bedpan in necessary. Option B, and D are all for pulmonary tuberculosis precautions. I suppose, the answer is A. place in a private room. 4) wat herb would help with vomiting? a. ginko b. ginsing. c. ginger root d. echinacea ****> ginger root is good for nausea.. most especially in morning sickness but in moderation for pregnant women... Option C is the answer 5) allergic to sulfa wat not to take? a. ma huang b. echinacea.
...I think the answer is... geez, i forgot..i think its Echinacea..let me check again ok.. 6) mother called a nurse from home stating that her child having chicken pox..which of the following statements by the mother needs immediate follow up? a. father of the child with liver failure b. sibling with anemia c. child just had tonsillectomy
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I think the answer is C. the child that just had tonsillectomy. i think the child is immunocompromised. and varicella pox) isAnd a viral one.. we all know that Cancel (Chicken Download Print tonsils are one of the lymph defenses we have against any infection.. Im not really sure with this answer. 7) client with allergy to sudafed ..which of the statments is correct? a. i will take valerian b. i will take ma huang c. i will take echinacea for acute viral inf. d. i will take black cohosh **valerian root is for cystitis and fungal infections; ma huang is for (I forgot!!),echinacea is for immune booster but not to be taken with patients with progressive systemic disorders such as AIDS, PTB, HIV, etc. black coh osh is for menopause. *** don't you think that Echinacea is the correct option??
8)food processing a. frozen food can be defrost for up to six hours b. frozen food which has been defrost can be return back to fridge. c. cook perishible food should cover and cool d. frozen food should be defrost by hot water usually, frozen food must be thawed at cool tap water for freshness. not in the microwave because it can be cooked outside and raw inside, not in the hotwater with same principle. so i believe, thawing it FOR UP TO 6 HOURS would be ok. returning thawed food back at fridge is ok but it is unsafe since salmonella can start thriving in.. Answer is OPTION A. 9) child in a mist tent and the parents brought him a car toy...the child was clutching the toy and the nurse refused to let him play for wot reason? a. it will get contaminated with bacteria b. it will accumalate moisture c. it could cause a fire ** The answer is OPTION C. Usually car toy have friction on it for the wheels to run.. Oxygen supports combustion.. and if friction is present together with oxygen (in a mist tent) then, fire could commence.
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a. did u warm up the formula Cancel Download And Print b. wot kind of formula did u give him c. does ur son feel hungry each time he throws up d. does r son have a jelly like stool ***>>> CORRECT OPTION is D.. Does your son have jelly like stool.. jelly like or currant like stool is a cardinal sign of Intussusception/ Telescoping or invagination of the large intestines in the Ileoceccal area.. 12) a patient had AIDS the nurse should advise? a. cook ur meat very well b. not to eat in the same table with family c. avoid crowds ***>> if you have AIDS, u are immunocompromised.. therefore you are prone to infection.. neutropenic precaution is advised and one that is a must is Avoiding Crowds.. Correct option is C. Posted by anaski from IP 203.131.185.106 on September 08, 2005 at 03:45:59: Thank you so much English RN2B Future USRNs, this for you: PRIORITY QUESTIONS (WHO TO SEE FIRST) Sample Test Item: 1. Which of the following clients should the nurse deal with FIRST? o 1 A client who needs his daily vitamin o 2 A client who needs to be suctioned o 3 A client who needs diaper to be changed o 4 A client who is being prepared for discharge Correct Answer: 2. A client who needs to be suctioned PRIORITY (Use ABC) Obstruction in the airway – secretions Need to be suctioned 2. Delegation, RN, LVN, UAP, CNA Which of the following clients should the LPN be assigned to? o 1 A newly diagnosed patient with MYASTHENIC CRISIS o 2 An immediate post-op client in PACU o 3 A client awaiting medication for vitamins o 4 A new admission for KIDNEY Transplant Patient Correct Answer: 3-stable, A client awaiting medication for vitamins Myasthenic Crisis – Unstable, Acute Respiratory Failure Immediate Post – op – Unstable, Risk for Complications, Kidney Transplant – Unstable, needs assessment for rejection
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In order to print this document from Scribd, you'll DELEGATION: Remember the 5R's, Right Task, Right Person, Right Circumstance, first need download it. Right Communication & Right to Feedback) RN Least stable, unstable, central catheters (hickman, broviac), admission, discharge, health teachings, patient for transfer, transfusion (2RNs) Cancel bloodDownload And Print LPN Technical Doer, Stable, medications, wound dressing CNA Routine Care, Urine Dip Stix, Reporting to RN, Routine VS UAP turning q2H, conducting group activities, ambulation For future USRNs This is for you... from the purkinje fibers of my heart.... Room Assignment(Who to Share Room with) Check: A ge B eside the nurse's station? At the end of the hallway? Single Room/Private Room? C hain of infection/circumstance D iagnosis E nviroment (dim light, darkened, red nightlapm) Sample Test Item: The best roommate for patient with LEUKEMIA is O 1 A 9-year-old with ruptured appendix O 2 A 12-year-old with chicken pox O 3 A 2-year-old with fever of unknown origin O 4 A 5-year-old with nephrotic syndrome Correct Answer: 4. A 5-year-old with nephrotic syndrome. 1,2 & 3, manifest symptoms of infection. A client with leukemia is immunosuppressed and Patients with infection shouldn't be placed in this room. Since patient with nephrotic syndrome receives diuretics and steroids, this child will also need immunocompromised host precaution. INFECTION CONTROL: Sample Test Item: 3. Which of the following methods should the RN utilize in patient with SALMONELLA? O 1 Airborne Precautions O 2 Droplet Precautions O 3 Neutropenic Precautions O 4 Enteric Precautions The correct answer: 4. Salmonella mode of transmission is fecal oral (enteric) Handwashing Gloves must be used in handling bedpan and diapers Gown - if soiling is likely to happen. Source of infection: Contaminated food and water. Remember - Transmission Based precautions: A ir B orne, small particles are dispersed in the air like MTB, varicella C ontact, drug-resistant microorganisms
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AGE APPROPRIATE GROWTH AND DEVELOPMENT Cancel Download And Print (HOPPING WITH ONE LEG) Sample test Item: 4. Which of the following is NOT a characteristic of a preschooler? O 1 predominantly "parallel play" period O 2 balances on 1 foot with eyes closed O 3 skips on alternate feet O 4 jumps rope The correct answer is: 1. Parallel play is more common in TODDLERS. Preschooler (3-6 years) Gross motor development HOPS ON ONE (1) FOOT BY 4 YEARS SKIPS & HOPS ON ALTERNATE FEET BY 5 YEARS PLAY : ASSOCIATIVE, IMAGINATIVE, MAGICAL THINKING, SUPERHEROES (Remember the movie: Jingle All The way!) FEAR: Intrusive procedures, venipunctures, IM injections, body mutilation Toxoplasmosis, where else you can contract this (thinking of cat litter but it aint there) Sample test Item: 5. To which of the following pregnant clients will be risk for TOXOPLASMOSIS? Select all that apply: O 1 A pregnant client who eat raw meat. O 2 A pregnant client handling cat litter of infected cats. O 3 A pregnant client gardening and cultivating soil exposed to cat feces. O 4 A pregnant client with low rubella titer O 5 A pregnant client who have undergone external radiation. O 6 A pregnant client with draining, painful vesicles in the external genitalia. The correct answers: 1, 2 & 3. TOXOPLASMOSIS How do people get toxoplasmosis? A Toxoplasma infection occurs by: Accidentally swallowing cat feces from a Toxoplasma-infected cat that is shedding the organism in its feces. This might happen if you were to accidentally touch your hands to your mouth after gardening, cleaning a cat's litter box, or touching anything that has come into contact with cat feces. Eating contaminated raw or partly cooked meat, especially pork, lamb, or venison; by touching your hands to your mouth after handling undercooked meat. Contaminating food with knives, utensils, cutting boards and other foods that have had contact with raw meat. Drinking water contaminated with Toxoplasma. Receiving an infected organ transplant or blood transfusion, though this is rare.
