NCLEX SUCCESS: What Does it Take? - · PDF fileNCLEX® SUCCESS: What Does it Take? ... Whatwould!be!the!appropriate!plan!of!care!for!aclientadmiked! ... the nursing care

4/8/15

2015, Copyright I CAN Publishing, Inc. 1

Lore%a Manning & Lydia Zager

April 6,7, 2015 1

NCLEX® SUCCESS: What Does it Take?

4/8/15


Page 14!

7

4/8/15


What would be the highest priority for a client 72 hours after having 2nd degree burns to 20% of his body in the lower abdominal area and both legs?

a. Airway b. Body Image c. Fluid & Electrolytes d. Pain

Strategy: P. 13-‐physiological integrity; Answer d

© 2013 I CAN Publishing®, Inc. 5

The nurse has received reports on the following pediatric clients. Which client should the nurse assess

initially?

a.  An 8-week-old client admitted 4 hours ago with substernal retractions and an oxygen saturation of 90%.

b. An 11- month-old client admitted 8 hours ago with dehydration whose vital signs are as follows: T - 99.7 degrees F, HR - 126, R-28.

c.   A 6-year-old client who had closed reduction of a fractured left tibia 2 hours earlier and has swelling of the left toes.

d.  A 14-year-old client who had an appendectomy 10 hour and has a 2.0 cm (1 inch) circular area of serous drainage on the dressing.

Strategy: P. 13-‐physiological integrity; Airway Answer a


4/8/15


A 30-year-old woman who suffered a head injury and began having seizures is being sent home on phenytoin (Dilantin). What is the priority for teaching the client about this drug?

a.  “If you stop taking the medication suddenly, an unpleasant, acute

withdrawal syndrome is likely along with renal failure.” b.  “You may stop taking this drug when you have had no seizures for six

months.” c.  “Let’s talk about what kind of contraception you plan to use while you

are taking ; this medication.” d.  “I know it’s depressing to face this, but you absolutely must take this

drug the rest of your life.” Strategy: P. 13- Assess; answer c © 2013 I CAN Publishing®, Inc.

7

A nurse is admitting a client with a diagnosis of posttraumatic stress disorder to the mental health unit. During this process,

the client becomes confused and disoriented. What is the priority intervention?

a. Accept the client and help to make client feel safe. b. Orient the client to the unit and introduce to the staff. c. Review the unit rules and provide a booklet outlining

them. d. Stabilize the client’s physical needs.

Strategy: P. 13- Maslow’s Hierarchy of Needs; answer a


4/8/15


Which of these clients should be assessed iniNally aOer report? A

client who is:

a.  36 weeks gestaNon with a BP 150 / 88, periorbital edema, +3 protein in urinalysis. b.  36 weeks gestaNon with a BP 160 / 90, headache, blurred

vision, and epigastric pain. c.  36 weeks gestaNon presenNng with painless bright red blood, FHR – 140, and good variability. d.  36 weeks gestaNon presenNng with rectal pressure, loss of

mucous plug, and 2 cm dilated. Strategy: P. 4-‐ Who is most unstable/highest risk for complicaNons or p. 6-‐ Early vs. late; answer b

9 © 2014 I CAN Publishing®, Inc.

Which of these nursing acNons from a UAP, for a client with a closed head injury, need immediate intervenNon by the nurse?

a. Takes vital signs as ordered and documents. b. Decreases the sNmuli in the room. c. Maintains seizure precauNons at the bedside. d.  Places client in the flat, supine posiNon during the bath and

back massage. Strategy: P. 5-‐ Organize around key concepts or P. 40-‐ Standard of Care; answer d

10

© 2013 I CAN Publishing®, Inc.

4/8/15


Which of the following is a desired outcome for a client taking

Mannitol for increased intracranial pressure?

a. Urine output 90 mL / hour. b. Serum sodium is 136 mEq / L. c. Glasgow Coma Scale has changed from 5 to 12. d.  Serum osmolality 280 mOsm/kg.

Strategy: P. 5-‐ Desired outcome; answer c

11


Which intervenNon would be a priority for the nurse to delegate to the

unlicensed assisNve personnel (UAP) for a client with diabetes ?

a.  Check the client’s technique for drawing up insulin into the syringe.

b.  Assist client with ambulaNng aOer assisNng with clipping toe nails. c.  Assist client with muscle cramps by applying a heaNng pad to

lower extremiNes while in bed. d. Check to make certain that the bath water is not too hot for the client.

Strategy: P. 5-‐ DelegaNon (Scope of PracNce) or P. 24-‐25; answer d

12


4/8/15


Which of these clients need to be seen first based on the trends in assessment findings?

a.  A client with a new chest tube that is Ndaling in the

underwater seal chamber and bubbling in sucNon chamber. b.  A client with a new tracheostomy who has thin, pale yellow secreNons. c.  A client with a hemothorax and chest tube whose BP went

from 138/88 to 98/50 and HR from 72 to 102 BPM. d.  A client with hemothorax and chest tube whose chest tube drainage went from 45mL/hour to 60 mL/ hr. Strategy: P. 5-‐ Trending (also on p. 8); answer c; PP. 8-‐9


TRENDING

©2014 I CAN Publishing®, Inc.

8-‐9

14

4/8/15


What would be the appropriate plan of care for a client admiked with the diagnosis of hepaNNs C (HCV)? Select all that apply.

p � Admit client to a private room with monitored negaNve-‐ airflow. p � Apply gown, mask, and gloves whenever nurse is in contact with the client. p � Apply a mask when in direct contact with client. p � Place in a semi-‐private room with a client with HIV; wear gloves when in contact with blood /body secreNons. p � Discard all needles and sharps in the appropriate containers; do not recap. Strategy: P. 6-‐ InfecNon Control or P. 63; answers 4, 5; pp. 63,73


Which of these acNons by a UAP when working with a post-‐CVA client who has right sided paralysis would require intervenNon by the charge nurse?

a.  The UAP takes the blood pressure on the leO arm. b.  The UAP places the wheel chair on the right side of the bed

when gemng client out of bed. c.  The UAP provides high-‐top tennis shoes for the client to

prevent foot drop. d.  The UAP approaches the client on the unaffected side when approaching the bedside. Strategy: P. 6-‐ Environmental Safety; answer b


4/8/15


The nurse has received reports on these obstetric clients. Which client should the nurse assess initially?

a.  A multipara client, one hour after a precipitate delivery, presenting with a BP- 98/62, HR-102, with pale and clammy skin. Fundus is firm and midline.

b.  A primigravida client who is presenting in the last trimester with a small amount of painless, bright red blood and FHR – 130 beats/ min with good variability.

c.  A primipara client, with an oxytocin infusion, who delivered an 8 lb. 4 oz. daughter 45 minutes ago.

d.  A postpartum client who delivered 20 hours ago, is presenting with a temperature of 1000F and in last 20 hours diuresed 2000 mlL.

Strategy: P. 6-‐ Early signs versus Late signs or P. 4 IdenNfy client who is unstable or highest risk for developing complicaNons; answer a 17


Which of these clinical findings for a client receiving magnesium sulfate require immediate intervention? (Select all that apply)

q 1. Blood pressure from 140 / 90 to 120 / 78. q 2. Hyperactive with complaints of insomnia. q 3. Hyperreflexic deep tendon reflexes. q 4. Respirations from 26 / min. to 14 / min. q 5. Urine output decreased from 80 mL / hr to 40 mL / hr.

Strategy: P. 5, 8-9-Trending; answers 4, 5; P. 463 18


4/8/15


Page 463

Which of these actions would be most appropriate for the nurse who is

working on a nursing unity with electronic medical records?

a. Log off from the computer prior to the end of the shift. b.  Remember, taking images (pictures) with the smart phone will assist in

providing the most objective and accurate documentation. c. With each use of the computer, click “submit” after entering data. d. Share password with a colleague that needs assistance.

Strategy: P. 10-11- INFOR MATICS; answer c; P. 10-11


4/8/15



The legal scope of pracNce must also reflect the Standard of

PracNce.

22

4/8/15


Old Test Taking Strategy: The UAP can ALWAYS assist a client

to ambulate. This is a test taking strategy for answering quesNons evaluaNng scope of pracNce for the NA / UAP.

Revised Strategy: Standard: “Provide care within the legal scope of

pracNce” “Assign and supervise care provided by others (e.g.

LPN/VN, assis<ve personnel, other RNs)”.

24


4/8/15


Page 25

Which intervenNon would be a priority for the nurse to delegate to the

unlicensed assisNve personnel (UAP) for a client with diabetes ?

1. Check the client’s technique for drawing up insulin into the syringe.

2. Assist client with ambulaNng aOer assisNng with clipping toe nails.

3. Assist client with muscle cramps by applying a heaNng pad to lower extremiNes while in bed.

4.  Check to make certain that the bath water is not too hot for the client.

4


4/8/15


Which intervenIons could the nurse delegate to the

UAP for a client with pneumonia? (Select all that apply.)

q 1. Assess breath sounds every shiS. q 2. Assist client in using a bedside commode. q 3. Encourage client to drink oral fluids. q 4. Teach client to cough and deep breathe. q 5. Assist with mouth care

2, 3, 5


LPN

P PLAN IN ISOLATION OF RN–LPNs plan in collaboration with the RN. They will not do this in isolation of the RN.

PUSH IV MEDICATIONS–The current LPN standard is not to push IV medications.

A ASSESS INITIALLY–LPNs will participate in ongoing assessments; however, the RN is responsible for the initial assessment.

ANALYZE–LPNs do not make nursing diagnosis or analyze the nursing care.

R REVIEW-EVALUATE IN ISOLATION OF RN–The LPN is responsible for collaborating with the RN during the evaluation process.

T TEACH INITIALLY–While LPNs may be involved in the teaching process, they are not responsible for initiating the teaching process.

4/8/15


A client with a history of heart failure suddenly exhibits shortness of breath, respiratory rate of 30, crackles auscultated bilaterally and frothy sputum. AOer calling the MD for orders, which of the following orders could the nurse delegate

to the LPN?

1.  Insert a urinary catheter. 2.  Monitor vital signs every 15 minutes. 3.  Administer morphine sulfate 2mg IV push

immediately. 4.  Start an intravenous line and cap it with a saline lock.

1


29

4/8/15


Which client should the charge nurse delegate to the new graduate RN who is orienNng to the neurologic unit?

� A 67-‐year-‐old client who had a CVA four days ago and has right-‐sided weakness.

� A 37-‐year-‐old newly admiked client with a spinal cord injury.

� A 57-‐year-‐old client with MulNple Sclerosis who needs assistance with bathing.

� An 87-‐year-‐old client with demenNa who is to be transferred to long-‐term care today.

1


Page 27

4/8/15


A medical surgical nurse is sent to work on the pediatric unit. Which child would be most appropriate to assign to this nurse?

1. 3 month-old in Bryant's traction 2. 5 day-old with jaundice 3. 7 year-old with diabetes 4. 14 year-old after scoliosis repair

4


Old Strategy: “NoNfying the provider of care” is ALWAYS a distracter because this is a nursing exam not a medical exam, and you should ALWAYS

do something first!

Revised Strategies: Standards: “Evaluate appropriateness and accuracy of

medica<on order for client” “Verify appropriateness and / or accuracy of treatment

order”


4/8/15


An 84-‐year-‐old client with diabetes mellitus has an order for an intravenous pyelopram (IVP). What is the priority of care for this client?

1. Assess for allergies to dyes. 2. Educate client regarding the procedure. 3. Obtain a consent from the client. 4. Verify appropriateness for procedure with healthcare provider

4.


Page 37

4/8/15


STANDARD OF CARE


41

DISCHARGE


43

4/8/15


Who would be most appropriate to refer to a client who has a spinal cord injury and needs

support in being independent?

1. OccupaNonal therapist 2. Chaplain 3. Physical therapist 4. DieNcian

1


STABLE


45

4/8/15


Which client should be discharged from the hospital first in order to provide a bed for a client

involved in a casualty?

1. A client scheduled for surgery in AM. 2.  A client admiked with vomiNng with serum

sodium level of 147 mEq/L. 3.  A client with recovering from Diabetes

Insipidus with a urine specific gravity of 1.001. 4.  A client with a hemoglobin of 8 g/dL

1


EDUCATES


47

4/8/15


What plan would be most appropriate prior to iniIaIng a teaching plan for a group of staff regarding a new piece of equipment?

1.  1. Distribute wriken informaNon regarding details about the topic.

2. Assess what staff already knows about the equipment.

3. Present in a manner that staff will understand.

4. Organize material into short sessions. 2


NCLEX-‐RN® 101: How to Pass! Safety: Management of Care: Chapter 2

(P. 31)

QUESTIONS: 1, 2, 4, 9, 11: PP. 32-‐33


4/8/15



4/8/15


SAFE EFFECTIVE CARE: Safety & InfecIon Control 15% -‐ P. 49 NCLEX 101 •  Principles of infection control (e.g., hand hygiene, room assign, isolation,

universal / standard precautions, etc.) •  Educate client and staff regarding infection control measures •  Verify appropriateness and / or accuracy of treatment order •  Protect client from injury/falls, elect. hazards, malfunctioning equip. or staff •  Report error / event / occurrence per protocol (e.g., medication errors, fall) •  Ergonomic Principles •  Implement emergency response plan (e.g., disaster, fire, etc.) •  Ensure proper identification of client when providing care •  Equipment / home safety •  Follow procedures for handling bio-hazardous material •  Restraint safety •  Protect client from injury •  Assess for client allergies / sensitivities and intervene as needed (e.g., food,

latex, environmental allergies) 47

Select the correct procedures when following standard precauNons. Select all that apply:��

q  1. Wear a face shield whenever entering the room. q  2. Wear gloves when coming in contact with any

body fluid. q  3. Place the client in a private room that has negaNve air pressure

in relaNon to surrounding area. q  4. Discard used needles immediately in the trash can. q  5. Wear gloves when entering the room. q  6. Avoid contact with client if nurse has an exudaNve lesion.

2, 6


4/8/15


Page 61

Page 53

4/8/15


Prior to administering the prescribed exenaNde (Byeka) subcutaneous, which of these observaNons would be most

important? Select all that apply. p � Bed number

p � Medical record number p � Name band p � Name of healthcare provider p � Room number

2, 3


The engineer causes an electrical fire during the installaNon of a new piece of equipment in the coronary intensive care unit. In the adjacent room, the client is on a venNlator. What should be the

priority of care at this Nme?

1. AcNvate the fire alarm. 2. Akempt to exNnguish the fire. 3. NoNfy the provider of care to remove the client off the venNlator. 4. Use an ambu bag and remove the client from the area.

4


4/8/15


RACE = FIRE SAFETY

R Rescue client A Activate alarm C Confine the fire E Extinguish the fire


93 89_ABCs.jpg89_ABCs.jpg

4/8/15


��Which of these nursing acNons would be the priority for a client

with a pulse oximeter that alarms indicaNng the oxygen saturaNon is at 86%?

1. Administer oxygen via mask. 2. Check the posiNon of the probe. 3. Reset the pulse oximeter’s alarm. 4. Complete a cardiovascular assessment.

2


A pediatric client is receiving an I.V. infusion. Which of these nursing acNons would be most appropriate for the nurse to

implement for this client? Select all that apply.

p � Check the pump prior to starNng the infusion to make certain it is working appropriately.

p � Check the alarm semngs when the client is reposiNoned in the bed. p � Check the alarm semngs aOer the client receives the medicaNon. p � Check the alarm semngs when infusion is started. p � Check the alarm semngs at the beginning of each shiO.


4/8/15


Which of these over-‐the-‐counter medicaNons should be

quesNoned for an older adult client who is high risk for falls? ��

1. Diphenhydramine (Benadryl) 2. Ferrous sulfate 3. Guaifenesin (Robitussin) 4. Loratadine (ClariNn)

1


NCLEX-‐RN® 101: How to Pass! Safety and InfecNon Control: Chapter 3

(P. 49)

QUESTIONS: 1 – 5: P. 50 15: P. 52 21: P. 53 23: P. 53 49: P.56


4/8/15


SIMPLEX AND ZOSTER


Page 67

PRIVATE


Page 73

4/8/15


REMOVING PPE


Page 83

CANE WALKING


Page 319

4/8/15



DELIRIUM AND DEMENTIA Page 541

Page 543

4/8/15


DYES


Page 119

Documents

NCLEX SUCCESS: What Does it Take? - · PDF fileNCLEX® SUCCESS: What Does it Take? ... Whatwould!be!the!appropriate!plan!of!care!for!aclientadmiked! ... the nursing care