Chamberlain College of Nursing - NR 466NCLEX-RN Live Review

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LIVE REVIEW Computer Adaptive Testing 75-265 Questions 15 Questions do not count End when eligibility level is determined Avg 2.5 hours with a 6 hour maximum www.pearsonvue.com/NCLEX​ ←- Onl... ine Tutorial Arrive at least 30 minutes EARLY. Bring valid photo ID. Formats ● Hot spot ● Drag and drop ● Multiple choice ● Fill in the blank Graphic Images Audio/Video 100 questions a day starting in June Nclex review book NCLEX items will be Knowledge based (to test recall and recognition) or ​Application (requiring use of nursing knowledge to solve the problem) Adverse effect of bronchodilator therapy 1. Increased myocardial oxygen use a. Bronchodilators cause tachycardia b. Decreases the amount of oxygen available for the rest of the body c. HYPO​kalemia and ​HYPER​glycemia are caused by bronchodilator therapy 2. Recurring calf pain after walking one to two blocks that disappears with rest. Weak pedal pulses, skin on left leg (lower leg) is shiny and cool to touch. Which nursing interventions? a. Intermittent claudication (arterial insufficiency) b. Position the leg dependently (put it down-blood will flow down) c. Venous insufficiency (leg would go UP) d. A​rterial (letters go down in the capital A) e. V​enous insufficiency (put the legs UP like the letters in V) Blood is only good for 4 hours (starting from when you leave the lab) 3. New tracheostomy, at home, the nurse recognizes a need for IMMEDIATE intervention when the caregiver does which of the following?LIVE REVIEW a. Life threatening! b. Removes old tracheostomy ties before the new ones are secured (decannulate themself) Maslow’s Hierarchy of Needs Self actualization (not a lot of questions) Self esteem (not a lot of questions) Love and belonging Safety and security Physiological - COMES first, unless there is an immediate risk for suicide ABC’s (not always airway first) Nursing process (not always assess first) Safety and risk reduction 4. Client sustained a c3 spinal cord injury. What finding should the nurse recognize as priority of care? ● C4 and above affects the muscles for breathing ● C1/C2 on a ventilator immed. ● Respirations 10/min would be the priority 5. Nurse prepares an older adult for a scheduled colonoscopy. Which should be the nurse’s INITIAL action? ● Place portable commode at bedside ● After physiological (prior to surgery so there are no physiological issues yet), next is safety. 6. Client ER reports HX Gravida 3 Para 2. Initial Action after observing a presenting part? ● Prepare for delivery of the newborn in the ER. ● Client is already effaced and fully dilated. ● If you can DELEGATE something to a non licensed person, it's not your priority. 7. Nurse enters the room of a client who is at the foot of the bed lying on the floow. Nurses initial action? ● Assess vital signs and LOC (before the person ended up on the floor, they had to be conscious) FIRST. Mass Casualties​ (Pg. 22) Up and down traffic light is the order you save them. Least Restrictive/invasive Acute OVER Chronic (Acute always take priority with one exception, the chronic condition has exacerbated to the point that it is life threatening ex. Status asthmaticus) Stable vs. Unstable Red​ immediate Yellow​ delayedLIVE REVIEW Green minor Black (Require the most man power, equipment, supplies, etc.) 8. Four days after ventral hernia repair, a client who is obese and has a hx of COPD vomits and reports severe abdominal pain. The oxygen sat is 90%. Which action should the nurse implement first? ● Assess the surgical incision site. ● Client is OBESE so that puts them at risk for dehiscence and evisceration. ● 90% for a COPD client is acceptable. 9. Client who is 24 hours post acute MI and reports “I can't breathe now that I am lying down after lunch” Nurse’s initial action ● Place client in high-fowler’s position ● Least invasive action 10. Nurse arrives at a work site explosion. Which client should be triaged first? ● Burns to the face and respiratory stridor (occlusion in airway) ● Fixed pupils and agonal respirations (random gasps of air) would get a black tag 11. Nurse is coordinating client care. Which client should the nurse delegate to the PN? A client who ● Requires insertion of an indwelling urinary catheter ● NOTHING new/initial. ● Only reinforcement 12. An adolescent client was admitted 12 hours ago following mvc. Multiple skeletal fractures were sustained. Client is in balanced suspension traction. Which assessment finding requires immediate intervention by the nurse. ● Disorientation (change is mentation/LOC)***** potentially life threatening. ● Bloody drainage at the pin site is an expected finding 13. Nurse provides care for a client who is scheduled for ECT. Which medication should the nurse withhold prior to therapy? ● Phenytoin (seizure medication) - You would not give this cause ECT causes seizures ● Atropine sulate (anticholinergic effects) ● Methohexital (short acting for sedation) ● Succinylcholine (paralytics) 14. A home health nurse is performing an admission assessment on a client who had a knee arthroplasty one week ago. Which client statement should concern the nurse the most? ● I am so glad to be off those blood thinners ● Risk for DVT ● Should be on anticoagulants: 3-6 months ● Pillow should be under calf and heel ● No wheelchair. Needs crutches or walker ● Ibuprofen is an NSAID and increases risk for bleeding on top of the blood thinners the patient is already consuming 15. Client has not voided 8 hours following the removal of an indwelling bladder catheter. What should be the nurse’s initial action? [Show More]

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