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Nclex study-Cris exam with correct answers.
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Nclex study-Cris exam with correct answers100-Sickle-cellbcrisis.bWhichbofbthebfollowingbnursingbactionsbshouldbthebnursebtakebFIRST?b-
bcorrectbanswer-
BeginbanbIVbwithbnormalbsaline.bDehydrationbperpetuatesbcellbsickling;bintakebshouldbbebatbleastb200bcc/ho
ur
Abclientbwithbabpacemakerbcallsbtobreportbthatbhebjustbhadbanbepisodebofbdizzinessbandbshortnessbofbbreat
h.b-bcorrectbanswer-ThebRnbshouldbaskb"Whatbisbyourbpulse?"
clientbreceivingbwarfarinb(Coumadin)b5bmgbPObdailybforbDVT.bThebnurseblearnsbthebclientboperatesbabhorseb
ranchb-bcorrectbanswer-Carrybabcellbphonebandbdressingsbandbtape.
nursebshouldbassignbabnursingbassistantbtobcarebforb-bcorrectbanswer-
AbclientbdiagnosedbwithbabCVAb2bweeksbagobrequiringbassistancebambulating.
Thebnursebcounselsbabclientbdiagnosedbwithbdegenerativebjointbdiseaseb-bcorrectbanswer-
"Placebyourbjointsbinbtheirbfunctionalbposition."maintainsbmobilitybofbjoints
Thebnursebpreparesbabclientbforbabskinbbiopsy.bWhichbofbthebfollowingbstatements,bifbmadebbybthebclient,bsh
ouldbthebnursebreportbtobthebphysician?b-bcorrectbanswer-
"Ibhavebbeenbtakingbaspirinbforbmybachingbjoints."aspirinbcanbincreasebthebriskbforbbleedingbandbshouldbbeb
reported
Abmanbhospitalizedbforbalcoholbabusebcomesbtobthebnurses'bstationbandbasksbthebnursebifbhebcanbgobtobtheb
cafeteriabtobgetbsomethingbtobeat.bWhenbtoldbthatbhisbprivilegesbdobnotbincludebvisitingbthebcafeteria,btheb
patientbbecomesbverballybabusive.b-bcorrectbanswer-
Calmlybbutbfirmlybescortbthebpatientbtobhisbroom.bLimit-
setting,bensuresbsafety;bpatientbwithbsubstancebabusebneedsbconsistent,bundividedbstaffbapproach,bclearlyb
definedbexpectations,basbwellbasblimit-setting;bavoidbthreatsbandbpromises
WhichbofbthebfollowingbpatientsbshouldbthebnursebseebFIRST?b-bcorrectbanswer-
AbpatientbcomplainingbofbchestbpainbwithbasymmetricalbchestbmovementbCORRECT—
bindicatesbflail;bmonitorbforbshock,bgivebhumidifiedboxygen,bmanagebpain,bmonitorbABGsbnoted.
,Twobdaysbafterbinsertion,bthebchestbtubebisbaccidentallybpulledboutbofbthebpleuralbspaceb-bcorrectbanswer-
Applybpressurebwithbabdressingbthatbisbtentedbonbonebside.b)bCORRECT—
bdecreasesbchancebthatbatmosphericbairbwillbenterbpleuralbspacebandballowsbforbescapebofbpleuralbair
90-
patientbhospitalizedbforbabheadbinjury.bThebclientbisbreceivingb0.9%bsodiumbchloridebatb100bcc/hbandbhasba
nbindwellingbFoleybcatheterbinbplace.bThebnursebnotesbthebpatient'sburinaryboutputbisb1,000bccbinb3bhours.b-
bcorrectbanswer-Measurebtheburinebspecificbgravity.bCORRECT—
blowbspecificbgravityb(1.001bandb1.005)bisbcharacteristicbofbdiabetesbinsipidus;bheadbinjurybcausesbinterfere
ncebwithbproductionborbreleasebofbADH;brecordbIbandbO,burinebspecificbgravity,bandbdailybweight;bensurebcli
ent'sbintakebofbfluidbandbadministerbDDAVP
WhichbofbthebfollowingbclientsbshouldbthebnursebseebFIRST?b-bcorrectbanswer-
Anbunconsciousbclientbwithbleft-sidedbtrachealbshiftbfrombmidlineCORRECT—
firstbsignbofbabtensionbpneumothorax;bairwaybandbbreathingbtakebpriorit
WhichbofbthebfollowingbmessagesbshouldbthebnursebrespondbtobFIRST?b-bcorrectbanswer-
Thebmotherbofbab15-year-oldbreportsbherbsonbisbthreateningbtobjumpboffbabbridgebandbhasbaccessbtobabgun.
CORRECT—
busingbMaslowbHierarchybofbNeedsbtheorybtobprioritize,bphysiologicalbissuesbtakebpriorityboverbpsychologic
albissues;bpatientbisbatbriskbforbselfbharmbandbmustbbebseenbfirst;bobservebforbsafety
WhichbofbthebfollowingbclientsbshouldbthebnursebseebFIRST?b-bcorrectbanswer-
Abclientb3bdaysbpostbrightbkneebreplacementbcomplainingbofbrightbcalfbpainbwithbmovement.(2)bCORRECT
—assessmentbforbpossiblebDVTbshouldbbebperformedbandbreportedbtobthebphysicianbimmediately
WhichbofbthebfollowingbclientsbshouldbthebnursebseebFIRST?b-bcorrectbanswer-Ab55-year-oldbreceivingb5-
fluorouracilb(5-FU).)bCORRECT—
bbecausebmanybchemotherapybagentsbmaybresultbinbneutropenia,bclientsbreceivingbdrugsbarebmorebsuscep
tiblebtobinfection,blessblikelybtobbebablebtobfightbthebinfection;bsymptomaticbclientsbrequirebimmediatebeval
uationbandbtreatment
Respondingbtobthebscenebofbabmotorbvehiclebcollisionb(MVC),bwhichbofbthebfollowingbclientsbshouldbthebnu
rsebseebFIRST?b-bcorrectbanswer-Anbunconsciousbclientbwithbabcrushingbchestbwound.2)bCORRECT—
bclientsbwithbcrushingbchestbwoundsbarebatbriskbforbabnumberbofbinjuriesbthatbmaybcompromisebairway,bbre
athing,bcirculation,bcervicalbspine,bandbthebnervousbsystem;bimmediatebevaluationbisbrequired
, WhichbofbthebfollowingbpatientsbshouldbthebnursebseebFIRST?b-bcorrectbanswer-Ab9-year-
oldbwhobhasbusedbabweaponbtowardbhisbmotherbandbcausedbphysicalbharmbtobothers.Ab9-year-
oldbwhobhasbusedbabweaponbtowardbhisbmotherbandbcausedbphysicalbharmbtobothers.
WhichbofbthebfollowingbpatientsbshouldbthebnursebseebFIRST?b-bcorrectbanswer-
Abpatientbwhobtookb10bmethylphenidateb(Ritalin)bandbhasbabbloodbpressurebofb160/100.CORRECT—
bmostbunstablebpatient;bassessbforbrestlessness,bdilatedbpupils,btremors,bandbseizures.bStimulantblikebamph
etamines,bimprovesbalertesnessbandbconcentration.
WhichbofbthebfollowingbpatientsbshouldbthebnursebseebFIRST?b-bcorrectbanswer-Ab35-year-
oldbwhobhadbabhysterosalpingogrambisbexperiencingbtachycardia,bandbhasbabgeneralizedbrash.(2)bCORRECT
—bx-
raybofbthebcervix,buterus,bandbfallopianbtubesbperformedbafterbthebinjectionbofbabcontrastbmedium;bassessb
forballergybtobshellfishborbiodine;brequiresbimmediatebattentionbbecausebpatientbhavingbanballergicbreactio
n
WhichbofbthebfollowingbpatientsbshouldbthebnursebseebFIRST?b-bcorrectbanswer-Ab7-year-
oldbwithbburnsbonbthebface.(2)bCORRECT—bburnsbcanbbeblife-
threateningbtobchildren;bairway,bbreathing,bandbcirculationbarebmajorbconcerns;bcardiopulmonarybcomplic
ationsbmaybresultbfrombexposurebtobelectricalbcurrent,binhalationbofbtoxicbfumes,bhypovolemia,bandbshock
WhichbofbthebfollowingbpatientsbshouldbthebnursebseebFIRST?b-bcorrectbanswer-
Abpatientbwithbabfastingbbloodbglucosebofb517bmg/dL.CORRECT—
bnormalbisb60btob110bmg/dL;brequiresbimmediatebattention;badministerbregularbinsulin
WhichbofbthebfollowingbpatientsbshouldbthebnursebseebFIRST?b-bcorrectbanswer-
Abpatientbreceivingbhaloperidolb(Haldol)bexperiencingbanboculogyricb.crisis.CORRECT—
beyesbareblockedbupward;bacutebdystonicbreaction;bnotifybphysicianbandbphysicianbwillborderbanbanticholine
rgicbagentbtobcorrectbthisbreaction
WhichbofbthebfollowingbpatientsbshouldbthebnursebseebFIRST?b-bcorrectbanswer-
Abpatientbdiagnosedbwithbhemophiliabcomplainingbofbjointbpain.bCORRECT—
bjointbpainbindicatesbbleeding;btreatmentbincludesbfactorbVIII,bRICEb(brbest,bibce,bcbompression,bandbeblevatio
n)
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