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NCLEX RN ACTUAL EXAM /RN NCLEX ACTUAL EXAM COMPLETE 500 QUESTIONS AND CORRECT DETAILED ANSWERS
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NCLEX RN ACTUAL EXAM /RN NCLEX ACTUAL EXAM COMPLETE 500 QUESTIONS AND CORRECT DETAILED ANSWERS
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NCLEX RN ACTUAL EXAM /RN NCLEX ACTUAL EXAMCOMPLETE 500 QUESTIONS AND CORRECT DETAILED
ANSWERS
Is a process of learning a different culture to adapt to a new or changing
environment. - ANSWER: Acculturation.
It is a subjective perspective of the person's heritage and a sense of belonging to a
group - ANSWER: Ethnic identity
Include meditation, relaxation techniques, imagery, music therapy, massage, touch,
laughter, humor, & spiritual measures (prayer). - ANSWER: Low-risk therapies:
Because of their health & dietary practices, Native Americans, Latino Americans,
Hispanic Americans, & African Americans. - ANSWER: High risk of obesity & diabetes
mellitus
Surgery is not prohibited, but the administration of blood and blood products is
forbidden. This religious group believes the soul cannot live after death.
Administration of medication is an acceptable practice except if the medication is
derived from blood products. - ANSWER: Jehovah's Witnesses
Believers adhere to dietary kosher laws. In this religion, the dairy-meat combination
is unacceptable. Only fish that have scales and fins are allowed; meats that are
allowed include animals that are vegetable eaters, cloven-hoofed, and ritually
slaughtered. - ANSWER: Orthodox Judaism
include whole medical systems, mind-body medicine, biologically based practices,
manipulative & body-based practices, & energy medicine. - ANSWER: Five categories
of complementary and alternative medicine (CAM):
Focused, maintains strong control, makes decisions, & addresses all problems.
Dominates group & commands, rather than seeks suggestions or input. Manager
addresses problem (quality improvement) with taff, designs a plan without input, &
wants all problems reported directly back to her - ANSWER: Autocratic leader
Participative & would likely meet with each staff person individually to determine
staff member's perception of problem. Would also speak with the staff about any
issues & ask the staff for input with developing a plan. - ANSWER: Democratic leader
Passive and nondirective. Would state what the problem was & inform staff that the
staff needed to come up with a plan to "fix it." - ANSWER: Laissez-faire leader
Assessment findings include cough, dyspnea, crackles, tachypnea, tachycardia,
elevated blood pressure, bounding pulse, elevated CVP, weight gain, edema, neck &
,hand vein distention, altered LOC, & decreased hematocrit. - ANSWER:
Overhydration or fluid overload & occurs when fluid intake or fluid retention
Avocado, bananas, cantaloupe, carrots, fish, mushrooms, oranges, potatoes, pork,
beef, veal, raisins, spinach, strawberries, & tomatoes - ANSWER: Common food
sources of potassium:
Muscle weakness, increased urinary output, & decreased specific gravity of the urine
would be noted - ANSWER: Hyponatremia
Causative factors relate to malnutrition or starvation & the use of aluminum
hydroxide-based or magnesium-based antacids. Malnutrition is associated with
alcoholism. - ANSWER: Hypophosphatemia
Renal insufficiency, hypoparathyroidism, & tumor lysis syndrome; causative factors.
Should avoid foods high in phosphates; fish, eggs, milk products, vegetables, whole
grains, & carbonated beverages. - ANSWER: Hyperphosphatemia
Vomiting, diarrhea, conditions that increased respiration's or increased urinary
output, insufficient intravenous fluid replacement, draining fistulas, presence of
ileostomy or colostomy. Diuretics, & gastrointestinal suctioning. - ANSWER: Causes
of a fluid volume deficit
Decreased kidney function, heart failure, hypotonic fluids to replace isotonic fluid
losses, excessive irrigation of wounds & body cavities, & excessive ingestion of
sodium. - ANSWER: Causes of overhydration or fluid overload:
Trauma, burns, sepsis, or metabolic or respiratory acidosis. - ANSWER:
Hyperkalemia causes:
Cushing's syndrome or colitis & over use of laxatives. - ANSWER: Hypokalemia
causes:
Decreased pH & decreased HCO3. Occurs in kidney disease; diabetic ketoacidosis;
high fat diet; insufficient metabolism of carbohydrates; malnutrition; ingestion of
toxins, such as acetylsalicylic acid (aspirin); malnutrition; severe diarrhea. Intestinal
secretion high in bicarbonate & may be lost through enteric drainage tubes, an
ileostomy, or diarrhea. - ANSWER: Metabolic acidotic
Nausea & vomiting. Loss of gastric acid, cause pH & HCO3 to increase. Symptoms
experienced would include hypoventilation & tachycardia. - ANSWER: Metabolic
alkalosis
Decreased pH and an increased CO2. Hypoventalation & COPD - ANSWER:
Respiratory acidotic
,Increased pH & decreased CO2. Hyperventalation, Lethargy, lightheadedness,
confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting,
epigastric pain, numbness & tingling of extremities. Hyperventilation (tachypnea)
occurs. - ANSWER: Respiratory alkalotic
Sample for PT & INR level to determine anticoagulation status & risk for bleeding -
ANSWER: Warfarin (Coumadin)
aPTT monitors the effects. Anticoagulant used most often during hemodialysis.
Monitors extent of anticoagulation checking PTT, which is appropriate measure
heparin effect. Protamine sulfate is antidote. - ANSWER: Heparin
Dark green leafy vegetables good source iron, oranges are a good source of vitamin
C, which enhances iron absorption. - ANSWER: Iron deficiency anemia foods in diet:
May lack B12 in diet. - ANSWER: Vegans
Include fruits & vegetables - ANSWER: Low sodium foods:
Highly processed or refined foods (tomato soup, instant oatmeal), Saltwater fish &
shellfish. Smoked foods, - ANSWER: High Sodium foods:
Water, bouillon, clear broth, carbonated beverages, gelatin, hard candy, lemonade,
ice pops, and regular or decaffeinated coffee or tea. - ANSWER: Clear liquid diet:
Pulling, Vegetable juice, Pureed vegetables, plain ice cream, sherbet, breakfast
drinks, milk, pudding & custard, soups that are strained, refined cooked cereals, &
strained vegetable juices. - ANSWER: Full liquid diet:
Pork products rich in this vitamin. Other good food sources include nuts, whole grain
cereals, & legumes. - ANSWER: High Thiamine foods
On the left side, with the head lower than the feet. This position used to minimize
effect of air traveling as a bolus to lungs by trapping it in right side of heart. -
ANSWER: Suspects air embolism. Should immediately place client in which position?
Assess for known allergies to eggs to prevent anaphylaxis. - ANSWER: Fat emulsion
(lipids)
Signs include excessive thirst, fatigue, restlessness, confusion, weakness, Kussmaul's
respirations, diuresis, & coma when severe. If has these symptoms, blood glucose
level should be checked immediately. - ANSWER: Hyperglycemia:
Temperature and weight: Temperature monitored to detect infection, potential
complication of therapy. Infection also could result in sepsis because catheter in
blood vessel. Weight monitored for effectiveness nutritional therapy & detect
hypervolemia. - ANSWER: Parenteral nutrition; PN monitor
, Burns, exacerbation Crohn's disease, persistent nausea & vomiting due to
chemotherapy. Had extensive surgery, multiple fractures, are septic, have advanced
cancer or AIDS. (Electronic infusion pump used to administer) - ANSWER: Parenteral
nutrition; Patients needing
10% dextrose in water until new PN solution becomes available. - ANSWER:
Parenteral nutrition; If PN bag empty hang
IV dislodged from vein & is lying in subcutaneous tissue. Pallor, coolness, & swelling
are results of IV fluid being deposited in tissue. Corrective action is remove catheter
& start new IV line at another site. - ANSWER: Infiltrated IV
Discomfort at site, redness, warmth, & swelling proximal to catheter. If phlebitis
occurs, discontinue IV line & insert new IV line at different site. Apply warm moist
compresses to area speed resolution of inflammation. Notify (HCP). Document
occurrence, actions taken, & client response. - ANSWER: Phlebitis at IV site:
Produces a rash, redness, & itching. - ANSWER: An allergic reaction at IV site:
Characterized by ecchymosis, swelling, & leakage at IV insertion site, as well as hard
& painful lumps at site. - ANSWER: Hematoma
Dyspnea, a swollen tongue, & cyanosis. - ANSWER: Hypersensitivity reaction:
Taught minor activity restrictions apply with this type of catheter. Protect site during
bathing & should carry or wear Medic-Alert ID. Have repair kit in home for use as
needed because catheter is for long-term use. - ANSWER: PICC line
Before beginning administration IV solution, assess whether chest radiograph reveals
central catheter is in proper place. Portable chest X-ray. - ANSWER: Central venous
catheter insertion:
Characterized by chills, fever, malaise, headache, nausea, vomiting, backache, &
tachycardia. - ANSWER: Systemic infection
Characterized by tachycardia, dyspnea, hypotension, cyanosis, decreased LOC,
anxiety, feelings of impending doom, chest pain, & hypotension. Place left side in
Trendelenburg's position. Lying left side may prevent air from flowing into
pulmonary veins. Trendelenburg's position increases intrathoracic pressure, which
decreases amount of blood pulled into vena cava during inspiration. - ANSWER: Air
embolism
Occurs with transfusion of blood contaminated with microorganisms. Signs include
chills, fever, vomiting, diarrhea, hypotension, & development of shock - ANSWER:
Septicemia
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