Archer Nclex day 1 (Cardiovascular) Questions With 100% Correct Answers.
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Archer Nclex day 1 (Cardiovascular) Questions With 100% Correct Answers.
A client is scheduled for gastroscopy at 8:00 AM and has been placed on NPO since midnight. At 6:30 AM, the nurse checks the client's capillary blood glucose level and gets a result of 40 mg/dl on the glucometer. The client...
Archer Nclex day 1 (Cardiovascular) Questions With
100% Correct Answers.
A client is scheduled for gastroscopy at 8:00 AM and has been placed on NPO
since midnight. At 6:30 AM, the nurse checks the client's capillary blood glucose
level and gets a result of 40 mg/dl on the glucometer. The client is alert, coherent,
and reports, "I feel fine. I don't feel anything." The most appropriate action for the
nurse is:
A. Record the finding in the notes and withhold the client's morning insulin.
B. Take a repeat sample of the capillary blood glucose.
C. Give the client simple sugar by mouth.
D. Administer intravenous dextrose 50 grams STAT.
Choice B is correct. The nurse should repeat the test because the client does not
display any symptoms of hypoglycemia. The glucometer readings are not always
accurate. Many variables such as quality of blood sample, dirt on the meter, humidity,
aged test strip, high hematocrit etc. may affect glucometer readings. In view of so many
variables affecting the blood glucose reading in glucometer, the nurse must be alert
while interpreting these values especially, in the absence of any symptoms.
Definition of hypoglycemia differs in diabetic patients differs from that of non-diabetic
patients. In diabetic patients, Hypoglycemia is defined as a blood glucose of less than
70mg/dl. Many diabetics may also have a condition called "Hypoglycemia
unawareness" where there may not be sufficient autonomic warning symptoms before
the onset of neuroglycopenia (impaired cognition, coma). In a diabetic patient, therefore,
hypoglycemia needs to be treated as soon as possible based on the lab values even in
the absence of overt symptoms.
In non-diabetic adults with low glucose level, one should assess for symptoms.
Symptoms may include cold, clammy skin, tachycardia, palpitations, impaired cognition,
slurred speech, seizures, and confusion. A low blood glucose at the time of symptoms
and improvement as soon as the blood glucose returns to normal confirm the diagnosis.
In a non-diabetic client who has been fasting, a blood glucose less than 50 mg/dL can
also be used to define hypoglycemia. In the absence of symptoms, however, the first
step is to recheck the blood glucose and confirm the result.
Choice A is incorrect. Because the first reading was too low, it is appropriate for the
nurse to recheck before documenting the findings to confirm accuracy.
Choice C is incorrect. The nurse should recheck and validate the results before deciding
to administer glucose.
Choice D is incorrect. The nurse should recheck and validate the results before deciding
to administer glucose. If the patient has significant symptoms, immediate IV dextrose is
appropriate.
The nurse is obtaining consent for surgery from a client. What should be the
initial action of the nurse while obtaining consent?
,A. Determine if the client has sufficient knowledge about the procedure.
B. Witness the signature of the client.
C. Tell the client that obtaining a signature is routine prior to surgery.
D. Explain the risks involved in the surgery.
Choice A is correct. "Informed" consent means that the client must understand the
procedure, the alternative options, and the risks and consequences involved. The nurse
should make sure that the client has sufficient knowledge about the procedure before
asking him to sign a consent.
While it is crucial for the client to know the risks of the procedure before signing the
consent, those risks should be explained to the client by the doctor, not the nurse.
Choice B is incorrect. The nurse should first assess the client's understanding of the
surgery/procedure before signing as a witness.
Choice C is incorrect. Procuring the client's signature for consent is routine before the
surgery. However, just telling this to the client does not satisfy the client's right to
informed consent.
Choice D is incorrect. Explaining the procedural risks involved is not the nurse's
responsibility and should be done by the doctor.
Which ergonomically designed work tool can prevent repetitive stress syndrome?
A. A back support belt
B. A special computer mouse
C. A special chair for sitting
D. Weighted pens and pencils
Correct Answer is B. A special ergonomically designed work tool that can prevent
repetitive stress syndrome, which is also referred to as carpal tunnel syndrome, is a
special computer mouse.
Choice A is incorrect. A back support belt is a protective device that may help to avoid a
back injury and not repetitive stress syndrome.
Choice C is incorrect. A special chair for sitting in correct posture prevents muscle
fatigue and maintains the body in the correct alignment with lumbar support, but it does
not prevent repetitive stress syndrome.
Choice D is incorrect. Weighted pens and pencils may be used by clients with poor fine
motor coordination, but they do not prevent repetitive stress syndrome.
Case management, as a form of patient care delivery and documentation, is most
closely aligned with:
A. The SOAP method of documentation
B. The SOAPIE method of documentation
, C. Variances
D. Case mix
Correct Answer is C. Variances, including patient variances, system variances and
practitioner variances are deviations from the expected plan of care and treatment that
is documented on the critical pathway of the case management method of patient care
delivery and documentation.
Choice A is incorrect. The SOAP method of documentation is part of the problem-
oriented medical record documentation system and not the case management method
of patient care delivery and documentation.
Choice B is incorrect. The SOAPIE method of documentation is part of the problem-
oriented medical record documentation system and not the case management method
of patient care delivery and documentation.
Choice D is incorrect. Case-mix reflects the collective conditions of the clients and it is
not part of the case management method of patient care delivery and documentation.
The obstetric nurse is reading the prenatal client's chart. The nurse notes that the
patient is suffering from preeclampsia and knows to observe for which
complications in the newborn?
A. Shaking and agitation
B. Low birth-weight
C. Abnormal kidney function
D. Blurred vision
The correct answer is B. The nurse with this patient should expect an infant born with
low birth weight. Preeclampsia often results in blood being shunted away from the fetus;
growth restriction is commonly found in infants born to these women.
Choice A is incorrect. Shaking and agitation aren't commonly connected with
preeclampsia. These symptoms may be related to drug abuse or gestational diabetes.
Choice C and D are incorrect. Blurred vision and abnormal kidney function affect
mothers who are suffering from preeclampsia, not their infants.
The nurse is caring for a patient receiving a blood transfusion. On assessment,
the nurse notes that the patient's respirations are rapid, the face is flushed, and
the patient is complaining of itching. The nurse suspects the patient is having a
transfusion reaction. The nurse should accomplish the following actions:
The nurse should complete the tasks in the following order:
A. Take vital signs
B. Stop the transfusion
C. Administer oxygen
D. Obtain a urine specimen.
The nurse should complete the tasks in the following order:
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