NCLEX/HESI Review Janine Messer BSN, RN POW Key Words Elimination Maslow Erickson ADPIE ABC Test taking strategies Do not fall into the trap of predicting answers on the NCLEX-PN. There is a temptation to select what you believe is the correct answer when you see it jump out at you from the answer choices. Don’t do it! Make sure to carefully consider each answer choice When doing a physical assessment of a 17year old primigravida who is at 30 weeks of gestation, a nurse should expect which finding is related to mild preeclampsia? 1. 2. 3. 4. Epigastric discomfort Trace proteinuria Dyspnea Blood pressure of 150/100 mm hg See it jump out from choice 4? This is the wrong answer Instead work your way through each choice and make eliminations After you read your choices carefully, you will see all findings are related to preeclampsia How do you choose? The question is asking about mild preeclampsia so choices 1,3, and 4 would be out because these are symptoms of severe preeclampsia Only choice 2 is related to mild preeclampsia You need to choose the best answer from the four you are given. This is where your practice of eliminating answer choices will really pay off What if every answer choice is correct? If you see the words:most, first, best, initial in a question, this means you must establish priorities You are picking the answer with the highest priority Prioritization A nurse responds to the cardiac monitor alarm of a patient and observes that the patient has atrial flutter. The patient is sitting up in bed and is responsive. Which of the following actions should the nurse take first? 1. Institute carotid sinus massage 2. Assess the patient for dyspnea 3. Initiate cardiopulmonary resuscitation for this patient 4. Place the patient in the Trendelenburg position Assess the patient for dyspnea Utilize PHAN Priority-Hierarchy-ABC’s-Nursing process(adpie) Always assess before you act When you see a question regarding care that includes both assessments and implementations in the answer choices, ask yourself, “Is there enough information given to take action?” If there is not, you must assess first In the previous question, three of the answer choices were implementations and only one answer (choice 2) involved assessment The Nursing Process The night after an exploratory laparotomy, a patient who has a nasogastric tube attached to low suction reports nausea. A nurse should take which of the following actions first? 1. Administer the prescribed antiemetic to the patient 2. Determine the patency of the patient’s nasogastric tube 3. Instruct the patient to take deep breaths 4. Assess the patient for pain Determine the patency of the patient’s nasogastric tube You can scan the choices immediately and see that two of the choices require you to take action and are therefore implementations (1 and 3) Choice 4 is tempting because you see the word “assess” but think further, is pain an issue for this patient? No….nausea is. When faced with both assessments and implementations, eliminate the implementations first unless you are certain the question gives you enough information to take action If the question does give you enough information to act, eliminate the answer choices involving unnecessary assessment Assess first and then Implement A nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. The next nursing action would be to: 1. 2. 3. 4. Call for help. Extinguish the fire. Activate the fire alarm. Confine the fire by closing the room door. Activate the fire alarm The order of priority in the event of a fire is to rescue the clients who are in immediate danger. The next step is to activate the fire alarm. The fire is then confined by closing all doors. Finally, the fire is extinguished. A nurse enters the nursing lounge and discovers that a chair is on fire. The nurse activates the alarm, closes the lounge door, and obtains the fire extinguisher to extinguish the fire. The nurse pulls the pin on the fire extinguisher. The next action would be to: 1. Aim at the base of the fire. 2. Squeeze the handle on the extinguisher. 3. Sweep the fire from side to side with the extinguisher. 4. Sweep the fire from top to bottom with the extinguisher. Aim at the base of the fire A fire can be extinguished by using a fire extinguisher. To use the extinguisher, the pin is pulled first. The extinguisher should then be aimed at the base of the fire. The handle of the extinguisher is squeezed, and the fire is extinguished by sweeping from side to side to coat the area evenly. A nurse is caring for a client who has hand restraints. The nurse assesses the skin integrity of the restrained hands: 1. 2. 3. 4. Every Every Every Every 2 hours 3 hours 4 hours 30 minutes Every 30 minutes The nurse needs to assess restraints and skin integrity every 30 minutes. Therefore options 1, 2, and 3 are incorrect. Agency guidelines regarding the use of restraints should always be followed. A nurse is assisting with planning care for a client with an internal radiation implant. Which of the following should be included in the plan of care? Select all that apply. 1. Wearing gloves when emptying the client's bedpan 2. Keeping all linens in the room until the implant is removed 3. Wearing a film (dosimeter) badge when in the client's room 4. Wearing a lead apron when providing direct care to the client 5. Placing the client in a semiprivate room at the end of the hallway Wearing gloves when emptying the client's bedpan Keeping all linens in the room until the implant is removed Wearing a film (dosimeter) badge when in the client's room Wearing a lead apron when providing direct care to the client A private room with a private bath is essential if a client has an internal radiation implant. This is necessary to prevent the accidental exposure of other clients to radiation. The remaining options identify interventions that are necessary for a client with a radiation device. A community health nurse is conducting a teaching session about terrorism with members of the community and discussing information regarding anthrax. The nurse tells those attending that anthrax can be transmitted via which route(s)? Select all that apply. 1. 2. 3. 4. 5. 6. Skin Kissing Inhalation Gastrointestinal Direct contact with an infected individual Sexual contact with an infected individual Skin Inhalation Gastrointestinal Anthrax is caused by Bacillus anthracis, and it can be contracted through the digestive system, abrasions in the skin, or inhalation. It cannot be spread from person to person. right right right right right patient drug dose route time 5 Rights of Medication Administration Does the order contain all necessary information? (5 rights of medication administration) Is the dose within the recommended range? Is the dose safe? Does the order contain all necessary information? (5 rights of medication administration) The most common error in medication calculation questions on the NCLEX is related to conversion (ie. Liters to milliliters) Remember to use the correct rules for rounding numbers Basic Rules for Dosage Calculations The medication prescribed is hydromorphone hydrochloride (Dilaudid), 3 mg intramuscular every 4 hours as needed. The medication label reads hydromorphone hydrochloride (Dilaudid), 4 mg/1 mL. The nurse prepares to administer how many mL to the client? 0.75 mL 3mg__ x 1ml= 0.75 mL 4mg The medication prescribed is digoxin (Lanoxin), 0.25 mg orally daily. The medication label reads digoxin (Lanoxin), 0.125 mg/tablet. The nurse prepares how many tablet(s) to administer the dose? 2 tablets 0.25 mg = 2 tablets 0.125 mg The medication prescribed is atropine sulfate, 0.4 mg intramuscularly, immediately. The medication label states atropine sulfate, 0.3 mg/0.5 mL. The nurse prepares how much medication to administer the dose? Round to the nearest tenth position. 0.7 mL 0.4 mg x0.5 mL = 0.66 mL= 0.7 mL 0.3 mg A nursing instructor asks a nursing student to describe the procedure for relieving an airway obstruction on an unconscious pregnant woman at 8 months' gestation. The student describes the procedure correctly if the student states to: 1. Place the hands in the pelvis to perform the thrusts. 2. Perform abdominal thrusts until the object is dislodged. 3. Perform left lateral abdominal thrusts until the object is dislodged. 4. Begin cardiopulmonary resuscitation (CPR) Begin cardiopulmonary resuscitation (CPR) If there's a visible blockage at the back of the throat or high in the throat, reach a finger into the mouth and sweep out the cause of the blockage. Be careful not to push the food or object deeper into the airway. If the object remains lodged and the person doesn't respond after you take the above measures initiate CPR. The chest compressions used in CPR may dislodge the object. Remember to recheck the mouth periodically. Options 1, 2, and 3 are incorrect and can cause harm to the woman and the fetus. A nurse on the day shift walks into a client's room and finds the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. The next nursing action is which of the following? 1. 2. 3. 4. Deliver breaths. Give the client oxygen. Start chest compressions. Ventilate with a mouth-to-mask device. Start chest compressions. The nurse would follow C-A-B, compressions, airway, and breathing. Therefore the next nursing action would be to start chest compressions. A nurse witnesses a neighbor's husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to open the airway. The nurse opens the airway in this victim with the use of which method? 1. 2. 3. 4. Flexed position Head tilt–chin lift Jaw thrust maneuver Modified head tilt–chin lift Jaw thrust manuever Prior to initiating cpr, remember to assess scene safety first. If a neck injury is suspected, the jaw thrust maneuver is used to open the airway. The head tilt–chin lift produces hyperextension of the neck and could cause complications if a neck injury is present. A flexed position is an inappropriate position for opening the airway. A nurse is developing a plan of care for a client who is scheduled for surgery. The nurse would include which of the following activities in the nursing care plan for the client on the day of surgery? 1. Have the client void immediately before surgery. 2. Avoid oral hygiene and rinsing with mouthwash. 3. Verify that the client has not eaten for the last 24 hours. 4. Report immediately any slight increase in blood pressure or pulse. Have the client void immediately before surgery The nurse would assist the client with voiding immediately before surgery so that the bladder will be empty. Oral hygiene is allowed, but the client should not swallow any water. The client usually has a restriction of food and fluids for 8 hours before surgery rather than 24 hours. A slight increase in blood pressure and pulse is common during the preoperative period; this is generally the result of anxiety. A nurse is caring for a client who is scheduled for surgery. The client is concerned about the surgical procedure. To alleviate the client's fears and misconceptions about surgery, the nurse should: 1. Tell the client that preoperative fear is normal. 2. Explain all nursing care and possible discomfort that may result. 3. Ask the client to discuss information known about the planned surgery. 4. Provide explanations about the procedures involved in the planned surgery. Ask the client to discuss information about the planned surgery Explanations should begin with the information that the client knows. Option 1 is a block to communication, and options 2 and 4 may produce additional anxiety in the client. A nurse is collecting data from a client who is scheduled for surgery in 1 week in the ambulatory care surgical center. The nurse notes that the client has a history of arthritis and has been taking acetylsalicylic acid (aspirin). The nurse reports the information to the surgeon and anticipates that the surgeon will prescribe which of the following? 1. Discontinue the aspirin immediately. 2. Continue to take the aspirin as prescribed. 3. Discontinue the aspirin 48 hours before the scheduled surgery. 4. Decrease the dose of the aspirin to half of what is normally taken. Discontinue the aspirin 48 hours before the scheduled surgery Antiplatelets alter normal clotting factors and increase the risk of hemorrhage. Aspirin has properties that can alter the clotting mechanism and should thus be discontinued at least 48 hours before surgery. A nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client's blood pressure (BP) is 100/60 mm Hg, the pulse is 90 beats per minute, and the respiration rate is 20 breaths per minute. On the basis of these findings, which of the following nursing actions should be performed? 1. 2. 3. 4. Shake the client gently to arouse. Continue to monitor the vital signs. Call the registered nurse immediately. Cover the client with a warm blanket. Continue to monitor the vital signs A slightly lower-than-normal BP and an increased pulse rate are common after surgery. The level of consciousness can be determined by checking the client's response to light touch and verbal stimuli rather than by shaking the client. Warm blankets are applied to maintain the client's body temperature. There is no reason to contact the registered nurse immediately. A client arrives to the surgical nursing unit after surgery. The initial nursing action is to check the: 1. Patency of the airway 2. Dressing for bleeding 3. Tubes or drains for patency 4. Vital signs to compare with preoperative measurements Patency of the airway If the airway is not patent, immediate measures must be taken for the survival of the client. After checking the client's airway, the nurse would then check the client's vital signs. This would then be followed by checking the dressings, tubes, and drains. A nurse is monitoring an adult client for postoperative complications. Which of the following would be the most indicative of a potential postoperative complication that requires further observation? 1. 2. 3. 4. A urinary output of 20 mL/hour A temperature of 37.6° C (99.6° F) A blood pressure of 100/70 mm Hg Serous drainage on the surgical dressing Urine output of 20 ml/hour Urine output is maintained at a minimum of at least 30 mL/hour for an adult. An output of less than 30 mL/hour for each of two consecutive hours should be reported to the surgeon. A temperature more than 37° C (100° F) or less than 36.1° C (97° F) and a falling systolic blood pressure less than 90 mm Hg are to be reported. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal. A nurse monitors the postoperative client frequently for the presence of secretions in the lungs, knowing that accumulated secretions can lead to: 1. 2. 3. 4. Pneumonia Fluid imbalance Pulmonary edema Carbon dioxide retention Pneumonia The most common postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes a productive cough, dyspnea, and crackles. Fluid imbalance can be a deficit or excess related to fluid loss or overload. Pulmonary edema usually results from left-sided heart failure, and it can be caused by medications, fluid overload, and smoke inhalation. Carbon dioxide retention results from the inability to exhale carbon dioxide in clients with conditions such as chronic obstructive pulmonary disease. Nice Job!!