Nclex Success

The nurse is caring for a client with status epilepticus. The MOST important nursing assessment of this client is
A. Intravenous drip rate
B. Level of consciousness
C. Pulse and respiration
D. Injuries to the extremities

A nurse from the maternity unit is floated to the critical care unit because of staff shortage. Which one of the following patients would be appropriate to assign to this nurse:
A) A client on Dopamine with vital signs monitored every five minutes
😎 A client who had an MI, but is free from pain and dysrhythmias
C) A client with a tracheotomy in some respiratory distress
D) A client with a pacemaker inserted this morning

While caring for a client receiving total parenteral nutrition (TPN) through a central line, the nurse notices a small trickle of opaque fluid leaking from around the central line dressing. It is MOST important for the nurse to take which of the following actions?
1. Prepare to change the central line dressing
2. Verify that the client is on antibiotics
3. Place the client’s head lower than his feet
4. Secure the Y-port where the lipids are infusing

Q. Clients with chronic obstructive bronchitis are given diuretic therapy. Which of the following reasons best explains why?
A. Reducing fluid volume reduces oxygen demand.
B. Reducing fluid volume improves clients’ mobility.
C. Restricting fluid volume reduces sputum production.
D. Reducing fluid volume improves respiratory function.

Q.What is the normal pH range for arterial blood?
🔴A. 7 to 7.49
🔴B. 7.35 to 7.45
🔴C. 7.50 to 7.60
🔴D. 7.55 to 7.65

Angelman syndrome (AS) is Associated with which chromosome abnormalities?
A. Chromosome13
B. 15
C. 18
D. 5

A community health nurse visits a client at home. The client states, “I haven’t slept at all the last couple of nights.” Which response by the nurse illustrates a therapeutic communication technique for this client?

1. “Go on.”
2. “Sleeping?”
3. “You’re having difficulty sleeping?”
4. “Sometimes, I have trouble sleeping too.”

Q.. The most common neonatal sepsis and meningitis infections seen within 24 hours after birth are caused by which organism?
A. Candida albicans
B. Chlamydia trachomatis
C. Escherichia coli
D. Group B beta-hemolytic streptococci
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Q. The most common early sign of kidney disease is:
A. Sodium retention
B. Elevated BUN level
C. Development of metabolic
acidosis
D. Inability to dilute or
concentrate urine

A client is in the recovery room following a carotid endarterectomy. Place the following assessments in priority order.
1. Neurological status.
2. Signs of hemorrhage.
3. Intracranial pressure.
4. Blood pressure.

Which nursing action(s) are appropriate for a nurse preparing to administer Phenytoin via a nasogastric (NG) tube? Select all that apply.

1) Hold tube feedings for at least one hour prior to administration.

2) Flush the nasogastric tube with 30mL tap water before and after administration.

3) Monitor blood pressure and heart rate every 15 minutes for two hours after administration.

4) Monitor liver function tests on a regular basis for patients taking Phenytoin.

5) Administer Phenytoin at the onset of new seizure activity.