NCLEX-RN Exam 183 Questions with Verified Answers 2020 Updated,100% CORRECT

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NCLEX-RN Exam 183 Questions with Verified Answers 2020 Updated Delegation - CORRECT ANSWER Right Person, Right Task, Right Circumstance, Right Communication, Right Supervision AP's: vitals and ... ALDs PN: stable clients and the expected outcome Bleeding - CORRECT ANSWER Stabilize object Colorectal Screening - CORRECT ANSWER Sigmoid: 5 yrs Colon: 10 years ages 50-75 Manual BP - CORRECT ANSWER 1 Inch above antecubital space Manual Systolic Measurement - CORRECT ANSWER Palpate radial pulse, inflate until pulse disappears, inflate another 30 mmHg, release and note when pulse is palpable again Clear Diet - CORRECT ANSWER Fruit juices, gelatin, broth Cane Use - CORRECT ANSWER On Stronger side. Move can, move weak leg, move stronger leg past cane Move 6-10 inches forward Infiltration - CORRECT ANSWER pallor, swelling, decrease skin temp stop, remove, elevate, ROM, cold compress, restart hypoxemia - CORRECT ANSWER early: Tachypnea, increased BP Late: Bradypnea, decrease BP Hypernatermia Risk Factors - CORRECT ANSWER older age, decrease total body water content, inadequate fluid intake, altered thirst Seizure precautions - CORRECT ANSWER Rescue equipment at bedside Fire Safety - CORRECT ANSWER R: Rescue A: Alarm C: contain E: extinguish P: Pull A: Aim S: Squeeze S: Sweep Radiation Precautions - CORRECT ANSWER wear monitoring badge for exposure Client Transfer - CORRECT ANSWER Fold arms of patient across chest while lifting head Positioning - CORRECT ANSWER Prone: on stomach, post lumbar puncture, tonsillectomy Supine: On back, spinal cord injury Crutches - CORRECT ANSWER 3 inch widths between axilla and top of crutch, hand grips with elbows at 30 degree Walker - CORRECT ANSWER Wrist even with hand grips Standard Precautions - CORRECT ANSWER Teir One protective equipment when in contact with blood and bodily fluids, dispose PPE in clients room, clean spills with bleach water Transmission Precautions - CORRECT ANSWER Airborne: N95 mask Droplet: Mask within 3 feet of patient Contact: gloves and gown Order of PPE - CORRECT ANSWER On: gown, mask, goggles, gloves OFF: gloves, goggles, gown, mask Precautions for Diseases - CORRECT ANSWER AIDS/HIV: standard Varicella: airborne C-diff: contact Hep A: standard Hep B: standard Hep C: standard Herpes simplex: standard shingles: airborne Measles: airborne Meningococcal: droplet MRSA: contact Pneumonia: droplet Respiratory syncytial virus: droplet Rotovirus: contact Rubella: droplet Salmonellosis: contact Shigellosis: contact TB: airborne Vancomycin resistant enterococci: contact Screening Guidelines - CORRECT ANSWER Physical: annually Dental: 6 months BP: 2 years BMI: every visit Cholesterol: 5 years glucose: 3 yrs colorectal: 10 yrs pap: 3 yrs breast exam: 3 yrs mammogram: yearly testicular examination: monthly prostate and rectal: yearly Morse Fall Scale - CORRECT ANSWER Secondary Diagnosis, mental status, IV locks, ambulatory aid, history of falls, gait Sodium - CORRECT ANSWER 135-145 sezuire precautions Potassium - CORRECT ANSWER 3.5-5 weakness, restlessness, irritability Magnesium - CORRECT ANSWER 1.3-2.1 facial flushing, calcification Calcium - CORRECT ANSWER 9.0-10.5 bone pain, constipation Pressure Ulcers - CORRECT ANSWER inspect every 2 hrs, barrier cream, turn every 2 hrs, 2,000-3,000 L/day, Vitamins A, C, zinc, shift weight every 15 mins Six Rights of Medication Administration - CORRECT ANSWER Right Med, Right Dose, Right Route, Right Documentation, Right Patient, Right Time Guidelines for IV - CORRECT ANSWER never administer meds through tubing being used for blood products Complications with IV's - CORRECT ANSWER Infiltration, extravasation, phlebitis, thrombophlebitis, hematoma, catheter embolism Infiltration Prevention - CORRECT ANSWER use smallest catheter for prescribed therapy, stabilize port-access, assess blood return Extravasation Prevention - CORRECT ANSWER know vesicant potential before giving medication Phlebitis Prevention - CORRECT ANSWER Rotate, secure, aseptic Hematoma Prevention - CORRECT ANSWER avoid veins not seen Catheter embolism Prevention - CORRECT ANSWER do not reinsert Complications of central venous catheter - CORRECT ANSWER Pneumothorax (ultrasound), air embolism (lie flat, valsalva maneuver) lumen occlusion (flush properly), bloodstream infection (sterile technique) Complications of PICC - CORRECT ANSWER Occlusion, dislodges, phlebitis, embolism, infection Care for TPN - CORRECT ANSWER serum glucose levels every 4-6 hrs, change dressing every 48-72 hrs, change IV tubing every 24 hrs Drug Classes - CORRECT ANSWER PRIL (ACE inhibitors) LAM (Benzos) ASONE (Corticosteroid) IDE (Oral hypoglycemic) PRAZOLE (PPI) ASE (Thrombolytics) PHYLLINE (bronchodilators) ARIN (anticoagulants) DINE (antiulcer) ZINE (antihistamine) TYLINE (trylic antidepressant) PRAM (SSRIs) Side Effects - CORRECT ANSWER ACE Inhibitors: Angioedema Benzos: Anterograde amnesia Beta Blockers: bronchospasm Ciprofloxacin: tendon rupture Digoxin: Yellow rings Doxycyline: tooth discoloration Furosemide: hypokalemia Lithium: tremors Tobramycin: ototoxicity Valacyclovir: thrombotic thrombocytopenia purpura ACE inhibitors - CORRECT ANSWER PRIL increases vasodilation, excretion of sodium and water HTN, HF, MI Angioedema = epinephrine Calcium Channel Blockers - CORRECT ANSWER DIPINE Angina, HTN slows calcium and increases dilation DO NOT GIVE TO HR or heartblock NO GRAPEFRUIT Alpha Adrenergic Blockers - CORRECT ANSWER ZOSIN dilation primary hypertension precautions for hypotension dizziness take at bedtime centrally acting alpha 2 agonists - CORRECT ANSWER decrease peripheral resistance Guanfacine and clonidine Primary Hypertension, hypertensive crisis, cancer pain Dry mouth, sore black tongue, leukopenia Beta Blockers - CORRECT ANSWER decreases cardiac exciatability, cardiac output, and oxygen demand HTN, angina, tachydyrthmias, HF, MI Bronchospasm's HOLD IF SYSTOLIC below 100 or HR below 60 Vasodilators - CORRECT ANSWER Nitro Increases dilation Digoxin - CORRECT ANSWER increases force, increases stroke volume, increase ventricular filling HF, A-fib Hypokelmoa, digoxin toxcitiy Apical pulse for 1 min before administration hold if under 60 Dysrththmias - CORRECT ANSWER Phenytoin Bradycardia - CORRECT ANSWER Atropine MS - CORRECT ANSWER eye patch for diplopia Cataracts - CORRECT ANSWER best vision until 4-6 weeks Brain Injury - CORRECT ANSWER occurs within 3 mins of no oxygen (brain death) Autonomic Dysreflexia - CORRECT ANSWER severe headaches, pallor, blurred vision, flushing above dermatome Air Leak Chest Tube - CORRECT ANSWER water seal chamber Tube Seperation - CORRECT ANSWER Exhale as much as possible and cough status asthmaticus - CORRECT ANSWER accessory muscles, distended neck veins COPD - CORRECT ANSWER encourage fluids, high calorie Signs of respiratory distress - CORRECT ANSWER tachypnea, tachycardia, dyspnea signs of pneumothorax - CORRECT ANSWER Hyper-resonance, dull percussion (hemo) tracheal deviation (tension) Bradycardia Treatment - CORRECT ANSWER Atropine, pacemaker A Fib Treatment - CORRECT ANSWER Adenosine, cardioversion V-tach without pulse - CORRECT ANSWER defib, lidocaine Pacer Spike Location - CORRECT ANSWER Before P or QRS if on T = LIFE THREATENING Valve replacement - CORRECT ANSWER life long anticoagulant therapy, replaced 7-10 years Labs - CORRECT ANSWER RBC: 4.2-5.4 WBC: 5,000-10,000 Platelets: 150,000, 400,0000 HGB: 12-16 HCT: 37-47 Hyponatremia Signs - CORRECT ANSWER hyperactive bowel sounds, seizures, bounding pulse, decrease DTR's, muscle weakness ABG's - CORRECT ANSWER PH: 7.35-7.45 PACO2: 35-45 HCO3: 21-28 Hiatal Hernia Prevention - CORRECT ANSWER avoid eating before bed Linaclotide - CORRECT ANSWER IBS, 30 mins before breakfast Pancreatitis - CORRECT ANSWER Tuners and Cullens sign NPO until pain free HIGH PROTEIN LOW FAT fetal lying, side lying, leaning forward positioning for comfort MONITOR GLUCOSE hemodialysis - CORRECT ANSWER assess BUN/Creatinine, hct x3 a week End Stage Kidney Disease - CORRECT ANSWER increase BUN and Creatinine, hyperkalemia, hypernatremia FVE, HF Chronic Kidney Disease - CORRECT ANSWER avoid NSAIDS, contrast DYE Fungal Specimen - CORRECT ANSWER Wooden tongue depressor Corticosteroids Topical Side Effects - CORRECT ANSWER Observe for thinning, striae, hypopigmentation Acromegaly - CORRECT ANSWER report postnasal drip and increase swallowing, HIGH FIBER Hyperthyroidism - CORRECT ANSWER avoid fish, shellfish, iodine Cushings Disease - CORRECT ANSWER hypersecretion Big S's (increase steroid, increase sugar, increase sodium, hypopigmentation) thin fragile skin, bruising, poor wound healing, hirsutism, balding Dexamethasone Supression Test - CORRECT ANSWER 24 hr urine collection Addisons Disease - CORRECT ANSWER Hypo secretion Small S's (low steroid, low sugar, low sodium, hyper pigmentation) loop thiazide = controls hyperkalemia Immunizations - CORRECT ANSWER localized tenderness (mobilize, cool compress, antipyretic for fever) Hydroxychloroquine - CORRECT ANSWER LUPUS, FREQUENT EYE EXAMS Lupus Risk Factors - CORRECT ANSWER starvation, diuretic use, CKD, obesity, trauma Radiation Adverse Effects - CORRECT ANSWER Skin changes, dysgeusia (altered taste), hair loss, fatigue Basal Cell Skin Cancer - CORRECT ANSWER small waxy nodules Allogenic Cells - CORRECT ANSWER matched donor Biopsy Lung Cancer - CORRECT ANSWER right side for 1-2 hrs after biopsy Regression - CORRECT ANSWER childlike behaviors Adaptive: child wets the bed Maladaptive: throws thing in office delirum - CORRECT ANSWER medical emergency Alcohol Withdrawal Manifestations - CORRECT ANSWER increase blood pressure, respiratory rate, and temp Easting Disorder Treatment Complication - CORRECT ANSWER Refeeding Syndrome anteograde amnesia - CORRECT ANSWER difficulty recalling events benzos complication Trycyclic antidepressants - CORRECT ANSWER BLOCKS, do not take with MAOI Lithium Toxicity - CORRECT ANSWER Early: 1.5, fine hand tremors Advanced: 1.5-2.0, coarse tremors Severe: 2.0-2.5, jerking movements Colestipol - CORRECT ANSWER lowers LDL take 4 hrs before other meds Niacin - CORRECT ANSWER lowers LDL Pancreatitis Gemfibrozil - CORRECT ANSWER lowers LDL Gallstones Filgrastim - CORRECT ANSWER increases production of neutrophils Bone pain, Leukocytosis, splenomegaly (adverse effects) PRAZOLE - CORRECT ANSWER decreases gastric acid, PPI Sucralfate - CORRECT ANSWER mucosal protectant Metoclopramide - CORRECT ANSWER controls Nausea and vomiting in chemo patients GERD Sulfasalazine/hydrocortisone - CORRECT ANSWER decreases inflammation, IBS, Crohns, ulcerative colitis Interacts with iron DO NOT CRUSH Iron - CORRECT ANSWER on empty stomach, harmless black stool, dilute liquid iron with water or juice (no milk), take with straw, rinse mouth Garlic - CORRECT ANSWER increases bleeding risk, vasodilator, block LDL Tamsulosin - CORRECT ANSWER Used for urinary retention Infliximab - CORRECT ANSWER flu-like symptoms, hypotension = STOP INFUSION monitor for 2 hrs immunosuppressant Alendronate - CORRECT ANSWER RONATE decreases osteoclasts, increase reabsorption Osteoporosis Monitor bone density every 12-18 months and calcium Calcitonin - CORRECT ANSWER Decreases osteoclasts and increases calcium excretion nausea is self limiting Propranolol - CORRECT ANSWER contraindicated in heart block, bradycardia, asthma, cardiogenic shock, HF Vasopressin - CORRECT ANSWER Antidiuretic, diabetes insipidus and CPR Topotecan - CORRECT ANSWER kills cancer cells, antimetic before chemo Flutamide Leuprolide - CORRECT ANSWER blocks testosterone Gentamicin - CORRECT ANSWER assess for hearing loss Ciprofloxacin - CORRECT ANSWER Tendon rupture, phototoxcity, supra infection Metronidazole - CORRECT ANSWER antibiotic, use condoms Prioritization - CORRECT ANSWER Systemic Acute Transient Emergencies, complications Autonomy - CORRECT ANSWER make ones own decisions Benefience - CORRECT ANSWER Do good Fidelity - CORRECT ANSWER Being faithful Justice - CORRECT ANSWER fairness Nonmaleficence - CORRECT ANSWER not to harm paternalism - CORRECT ANSWER right to make decisions for another Patient Bill of Rights - CORRECT ANSWER humane care Unintentional Torts - CORRECT ANSWER negligence and malpractice Quasi-intentional torts - CORRECT ANSWER confidentiality intentional tort - CORRECT ANSWER assault, battery, false imprisonment Mass Casualty Triage - CORRECT ANSWER Red: immediate threat to life Yellow: major injuries, can delay 30 mins-2hrs) Green: Minor injuries, can delay for 2 hours Black: expected and allowed to die cultural humility - CORRECT ANSWER Self reflection ambivalence - CORRECT ANSWER understanding the pregnancy (1st trimester) Accepting - CORRECT ANSWER second trimester preparing for birth - CORRECT ANSWER 3rd trimester Respiratory Dyspnea - CORRECT ANSWER 2nd and 3rd trimester Nausea and Vomiting - CORRECT ANSWER 1st and 3rd trimester Monitor for hyperemesis Heartburn - CORRECT ANSWER 2nd and 3rd trimester Urinary Frequency - CORRECT ANSWER 1st and 3rd trimester Braxton Hicks contractions - CORRECT ANSWER 2nd and 3rd trimesters Nutrition - CORRECT ANSWER 25-35 lbs total 300-400 kal/day 25g Protein 600 Folic Acid Iron 30mg Ultrasound - CORRECT ANSWER full bladder Nonstress test - CORRECT ANSWER fetal heart rate biphysical profile - CORRECT ANSWER movements Breathing, movements, gross body movements, heart rate, NST FHR, amniotic fluid volume amniocentesis - CORRECT ANSWER 14-16 weeks LATE: administer Rhogram IF NEEDED Maternal serum alpha-fetoprotein (MSAFP) - CORRECT ANSWER Neural Tube Defects 16-18 weeks GTPAL - CORRECT ANSWER Gravity, Term, Preterm, Abortion, Living Initial Labs - CORRECT ANSWER CBC, blood type, urinalysis, STI SCREENING (HIV, RUBELLA, HEP B) 28 Weeks Screening - CORRECT ANSWER Diabetes 35 Weeks Screening - CORRECT ANSWER Group B Strep mild preeclampsia - CORRECT ANSWER proteinuria 1-2 + Severe Preeclampsia - CORRECT ANSWER visual disturbances Eclampsia - CORRECT ANSWER seizure activity, epigastric pain HELLP syndrome - CORRECT ANSWER H: hemolysis EL: elevated liver LP: low platelets Risk to Newborn when mother has diabetes - CORRECT ANSWER macrosomia, hypoglycemia Placenta Previa - CORRECT ANSWER BRIGHT RED, NO PAIN (bed rest or c-section) age over 35, smoking, cocaine, scar tissue from other pregnancies abruptio placentae - CORRECT ANSWER DARK RED, Boardlike very tender (c-section, blood products, monitor DIC) Trauma, preeclampsia, multiparty, cocaine Cervical Insufficiency - CORRECT ANSWER premature dilation pink stained vaginal discharge Ectopic Pregnancy - CORRECT ANSWER Unilateral stabbing Stages of Labor - CORRECT ANSWER First Stage (Latent, Active, Transitional) Second Stage (pushing, assess FHR every 15 mins) Third Stage (delivery of placenta, care of newborn) Fourth Stage (breastfeeding, bonding, fundus, hemorrhage!) VEAL CHOP MINE - CORRECT ANSWER V: variable E: early A: acceleration L: late C: cord H: head O: okay P: placenta M: move I: identify N: nothing E: execute! Oxytocin - CORRECT ANSWER induces labor, contracts fundus (increase until desired effect) Misoprostol - CORRECT ANSWER softens and thins cervix Penicillin G - CORRECT ANSWER Group B strep Methylergonovine - CORRECT ANSWER hemorrhage Terbutaline - CORRECT ANSWER preterm labor Betamethasone - CORRECT ANSWER fetal lung maturity Methotrexate - CORRECT ANSWER ectopic pregnancy, avoid folic acid and sun exposure Indomethacin - CORRECT ANSWER tocolytic in preterm labor Oxygen Delivery Pregnancy - CORRECT ANSWER 8-10L nonrebreather mask Postpartum - CORRECT ANSWER Milk Production: 2-3 days after Uterus: decreases 1cm/day Lochia: bright red, 1-3 days Serosa: brownish, 4-10 days Alba: yellow/white, 6 weeks Hemorrhage - CORRECT ANSWER one pad or more within 15 mins Infections Postpartum - CORRECT ANSWER Endometritis: 2-5 day Mastitis: 2-4 weeks Vitals Newborn - CORRECT ANSWER RR: 40-60 HR: 100-160 T: 97.7-98.9 Newborn Head - CORRECT ANSWER 2-3 cm larger than chest circumference eye prophylaxis - CORRECT ANSWER erythromycin and tetracycline 1 hr after birth Newborn Labs - CORRECT ANSWER CBC, RH, glucose, bilrubin Feedings - CORRECT ANSWER Immediately after birth 2-3 hours Breastfeeding 3-4 hours formula Circumcision Care - CORRECT ANSWER change diaper at least every 4 hours Cancer Risk in Women - CORRECT ANSWER HPV, multiple partners bleeding, pain pap test, DNA test safe sex Breast Cancer - CORRECT ANSWER family history, lifestyle lump, discharhe mammo, breast exam Menopause - CORRECT ANSWER hot flashes, vaginal dryness, decrease bone density IUD - CORRECT ANSWER monitor monthly, preg test pap test and cervical cultures before insertion Prenatal visits - CORRECT ANSWER 12 weeks and monthly assess fetal movement at 16-20 weeks Milk Storage - CORRECT ANSWER Room temp: 8 hrs Refrigerator: 8 days Freezer: 6 months Deep Freeze: 12 months DO NOT REFREEZE MILK Alcohol Withdrawal in Newborn - CORRECT ANSWER increase tone and reflex, seizures, irritability, jitterness small eyes, flat midface, thin upper lip, poor suck, epicantheal folds [Show More]

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