Pn 154 Nclex Review

7/24/2019 Pn 154 Nclex Review

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PN 154

NCLEX Review

Spring 2010

Instructor: Lisa Lee Rohm, RN, BSN

Creator of this fabulous PowerPoint:

Amber Lee, RN, BSN!!


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Concordes Process

A preliminary Caniate list! is mae an sent to"SBN, #ho then sens the list to $earson %ue

Applications &'oth (or "SBN an $earson %ue),(ingerprinting, * passportphoto #ill 'e sent 'y

Concore to the appropriate places +ou may receie your Authori-ation to .est &A..)prior to "SBN receiing the o((icial transcripts,ho#eer i( you ta/e the eam 'e(ore your transcriptsare receie, you #ill not receie a nursing licenseuntil a(ter the entire process has 'een complete

"n the grauation ate, Concore #ill sen theo((icial Caniate List! to "SBN

hen all o( the graes an SIGNED&'y you an theinstructors) ealuation (orms are turne in, the o((icial

transcripts #ill 'e sent to "SBN


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Application Hints

o not change your name or you appearance(rom the time you (ill out the application an ta/eyour passport picture until you receie your

license o not (ill out the 'lue (ingerprinting car until you

are in the presence o( the (ingerprinter!

3or the (ingerprinting ay:

4a/e sure you are #ell hyrate an your hans aremoisturi-e

I( you hae callouses, seriously consier ao)manicure


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Application Hints (Just sa! "es#$

I( you hae any yes! ans#ers on your B"N app5A short, one paragraph, eplanation is su((icient

"n the chemical su'stances 6uestion, say yes!

een i( you hae a prescription5 .he 6uestion reas 7ae you ever 'een

arreste, charge #ith, entere a plea o( guilty,no contest, conicte o( or 'een sentence

(or 555!Ans#er yes! een i( the recor has 'een

epunge &8uenile or ault) I( you say no! an it someho# sho#s up on your

'ac/groun chec/, this #ill elay your process


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How to apply for anOregon Nursing License

(step % step process$

www&os%n&state&or&us')*N'new

+raduates&s,t-l


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How to appl .or initial

licensure in anot,er state

###5ncs'n5org

&Clic/ on Boars o( Nursing!, then mem'er'oars,! then clic/ on the state you #ant to 'e

license in)
http://www.ncsbn.org/http://www.ncsbn.org/


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How to re+ister .or t,e

NCLEX

https://www.ncsbn.org/2009_NCLEX_Can!ate_"#$$et!n.p%

orwww.ncsbn.org/E!ght_steps_o%_NCLEX.p%

&%or overv!ew'
https://www.ncsbn.org/2009_NCLEX_Candidate_Bulletin.pdfhttps://www.ncsbn.org/2009_NCLEX_Candidate_Bulletin.pdfhttp://www.ncsbn.org/Eight_steps_of_NCLEX.pdfhttp://www.ncsbn.org/Eight_steps_of_NCLEX.pdfhttp://www.ncsbn.org/Eight_steps_of_NCLEX.pdfhttp://www.ncsbn.org/Eight_steps_of_NCLEX.pdfhttps://www.ncsbn.org/2009_NCLEX_Candidate_Bulletin.pdfhttps://www.ncsbn.org/2009_NCLEX_Candidate_Bulletin.pdf


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)c,edulin+ "our E/a-

Concore #ill sen "SBN a Caniate list! #ho #illthen sen $earson %ue a Caniate List!

A(ter your 'oar o( nursing eclares you eligi'le, you#ill receie your Authori-ation to .est &A..)

$earson %ue #ill mail each person their A..5

A(ter you receie your A.., you may scheule yourtest #ith any $earson %ue .esting Center &200locations) "regon testing centers: Beaerton, Salem, 4e(or

Aerage test ate is 29 ays (rom the ate o( scheuling

+ou must ta/e the eam #ithin 0 ays o( receiingyour A.. &'ut a(ter grauation ate ;


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)c,edulin+ "our E/a-

>ach A.. is ali (or the perio o( time speci(ie'y the 'oar o( nursing &B"N) &0 ays)5

"nce the B"N has eclare you eligi'le to test

an your A.. is issue, you must test #ithin thealiity ates o( your A..5

(hese va$!!t) ates cannot be e*tene %oran) reason. I% )o# o not test w!th!n these

ates+ )o# w!$$ have to re,reg!ster an )o#are respons!b$e %or the -200.00 pa)ent.


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*e.ore t,e da o. t,e test0

>pect an prepare (or stress

Be prepare (or others to leae the testingcenter 'e(ore or a(ter you

Bring #ater an snac/ to /eep in the loc/er $lan alternate routes to the testing (acility

+ou can ta/e a irtual tour o( your testing (acility

'y going to: ###5pearsonue5com


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a o. 2est0

Bringto 2estin+ Center

(( $etter? +ou #ill not 'e amitte to the eam#ithout your A..5 +ou #ill 'e re6uire to re@registeran re@pay to ta/e the eam &200500)5

2 (orms o( I, one #ith photo, 'oth #ith signature 3irst an Last name must e*act$)match the

name on your A.. letter LIDriers License or State I or $assport

&4S. N". B> >D$IR>) an must inclue aphotograph an signature

A sa$$ storage space is proie


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a o. 2est

1$an to arr!ve 0 !n#tes be%ore )o#rsche#$e test!ng t!e. &I( you arrie lateyou may 'e re6uire to (or(eit your

appointment5 +our (ailure to ta/e the eam#ill 'e reporte to the B"NE)

.he test aministrator &.A) #ill proie you#ith an erasa'le note 'oar that may 'e

place


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a o. 2est0 o Not *rin+

Any stuy materialsE 7ats, Scares, Coats, $hones, atches, $ager $aper


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a o. 2est

+ou #ill 'e (ingerprinte, photo ta/en, anas/e to illustrate your signature5

>arplugs proie i( neee5

Cloc/ starts as soon as you are logge in!5

+ou hae = hours to complete the NCL>D@$N5

+ou #ill receie a tutorial 'e(ore the eam to(amiliari-e you #ith the computer5


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a o. 2est

"ptional Brea/s proie at 2 hours, an at G5=hours

Brea/s count against your testing time, #hen youreturn (rom 'rea/, you #ill 'e (ingerprinte again

+ou #ill 'e as/e to complete a surey at the en

o( the eam

o not gie any in(ormation a'out the eam toanyone, incluing instructorsE


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a o. 2est

.he test aministrator &.A) #ill proie you#ith an erasa'le 'oar that may 'e replaceas neee uring testing5

.he .A #ill gie you a short orientation anthen #ill escort you to a computer terminal5+ou must remain in your seat uring theeam, ecept #hen authori-e to leae 'y

test center sta((5 +ou may not change your computer terminal

unless a .A irects you to o so5


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a o. 2est

Raise your han to noti(y the .A i( +ou: Beliee you hae a pro'lem #ith your computer

Nee to change note 'oars

Nee to ta/e a 'rea/ Nee the aministrator (or any reason

hen you hae (inishe the test an6uestionnaire, raise your han5 .he .A #ill

collect an inentory all note 'oars5 .he .A #ill ismiss you #hen all re6uirements

are (ul(ille5


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34 ,ours a.ter t,e NCLEX

Results #ill not 'e release until the Boar o(Nursing receies you o((icial transcripts (romConcore

"regon License %eri(ication &(ree):###5oregon5go


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Co--on uestions and 6t,s A%out

t,e NCLEX

$assing Score epens on #hat the aeragescore o( all people ta/ing the test across thenation

.heres lots o( rug 6uestions

Can you hae a piece o( scratch paper


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Co--on uestions and 6t,s

A%out t,e NCLEX It is harE

Can you ta/e the NCL>D in another stateH

7o# many times can you reta/e the eamH

.est@ta/ers are selecte ranomly to ta/e a

certain num'er o( 6uestions5

I( you miss a 6uestion on a particular su'8ect,you #ill get more 6uestions on that topic5


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7"8

"SBN is no# re6uiring that you noti(y them o(name changes, aress changes, email changes,employment changes, an lost car

+ou must #or/ ;0 hours


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2est *rea9down

J=@ 20= 6uestions &.here are thousans o( 6uestions inthe test 'an/)

2= pre@test 6uestions on eery NCL>D@$Neam &;0 o((icial plus 2= pre@test 6uestions ma/e up your (irstJ= 6uestions)

$re@test 6uestions are #ritten 'y nurses

Kuestions are reie#e 'y Item Reie#ers! #hoare nurses that are currently practicing nursing

Kuestions must 'e approe 'y a $anel o(uges!

.hen the 6uestions #ill 'e pre@test! 6uestions

+ou #ill not /no# #hich 6uestions count to#arsyour eam


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NCLEX *rea9down

p to = hours to ta/e the eam &Spee per6uestion is not a (actor in the (inal score, 'ut (igure appro5 1minute per 6uestion)

>am #ill en #hen:At least the minimum num'er o( 6uestions

&J=) 6uestions are ans#ere an there is a= certainty the test@ta/er #ill pass or (ail

4aimum num'er o( 6uestions &20=) hae'een ans#ere

4aimum time &= hours) has passe


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Pass or 7ail:

It is impossi'le to ta/e a test #hich #ill coereery su'8ect, it #oul 'e #ay too long anta/e too much time5

Instea the computer ecies 'ase o(( yourans#ers to a minimum amount o( 6uestions#hether it is = certain you #oul pass or(ail i( you ans#ere eery 6uestion on eery

su'8ect5


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Passin+ wit, ;5< Con.idence


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7ailin+ wit, ;5< Con.idence


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Pass or 7ail:

A(ter J= 6uestions the computer #ill 'eginto etermine the = con(ience

I( at J= 6uestions, the test ta/er is not

passing or (ailing, you #ill continue toans#er 6uestions until there is =con(ience, on #ay or another5

"R


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Pass or 7ail:

I( the maimum num'er o( 6uestions &20=)has 'een reache or = hours has passe,an the computer can still not etermine a

= con(ience: .he computer #ill loo/ 'ac/ at the last ;0

6uestions5

I( at any point the test ta/er (alls 'elo# the

stanar@ the test ta/er (ails5 I( the test ta/er remains a'oe the

stanar (or the last ;0 6uestions, they

pass


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),ould ou =+ive up> i. ou ta9e -ore

t,an 5 ?uestions:


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N#Stay (ocuse5 Rela5 +ou still hae

plenty o( opportunities to pass5

.est ta/ers #ho too/ 20= 6uestions

hae passe


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uestions A%out How CAT

works:

National Council o( State Boars o(Nursing, Inc5 &NCSBN) ###5ncs'n5org .oll (ree: 15J;;52G5;00 >@mail: nclein(oMncs'n5org


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Pass Rates

2003

J9 test ta/erspasse on the (irst

time 9= o( all the test

ta/ers in 2009

passe the NCL>D

2004

J= o( test ta/ershae passe on the

(irst time 9J o( test ta/ers

hae passe the

NCL>D so (ar

@"our %est c,ance to pass is to ta9e t,e e/a- sooner t,an later@

(1-ont,$


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B,at 8. 8 7ail:

+ou #ill receie aper(ormance report

in the mail, #hich#ill sho# you your#ea/ areas

+ou may reta/e the

eam a(ter = aysas many times as itta/es (or up to threeyears


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NCLEX RE8EB

NCL>D .>S.$LAN

###5ncs'n5org


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Co-ponents o. 2est Plan

>ach eam 6uestion aresses:A leel o( cognitie a'ility

A client nees category

An integrate process


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Levels o. Co+nitive A%ilit

Ono#lege Recall

Comprehension

Application

Analysis


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5now$ege: recall

A nurse reie#s the la'oratory results o( aclients 'loo glucose leel5 .he nurse /no#s

that #hich o( the (ollo#ing is a normal leelH 15) 0mg


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5now$ege: recall

A nurse reie#s the la'oratory results o( aclients 'loo glucose leel5 .he nurse /no#s

that #hich o( the (ollo#ing is a normal leelH 15) 0mg


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Coprehens!on: unerstan in(ormation anra# in(erences 'ase on that in(ormation

A hospitali-e client #ith .ype 1 ia'etes

mellitus complains o( hunger annerousness an the nurse notes that theclient is iaphoretic5 .he nurse unerstansthat the client is most li/ely eperiencing:

15 aniety relate to the hospitali-ation 25 signs relate to an in(ection G5 a hyperglycemic reaction 5 a hypoglycemic reaction


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Coprehens!on: unerstan in(ormation anra# in(erences 'ase on that in(ormation

A hospitali-e client #ith .ype 1 ia'etes

mellitus complains o( hunger annerousness an the nurse notes that theclient is iaphoretic5 .he nurse unerstansthat the client is most li/ely eperiencing:

15 aniety relate to the hospitali-ation 25 signs relate to an in(ection G5 a hyperglycemic reaction P5 a hypoglycemic reaction


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pp$!cat!on: Interention, nursing action,ecision or pro'lem that nees to 'earesse

A client is eperiencing a hypoglycemicreaction5 .he nurse aministers #hich 'estitem to the client to treat the reactionH

15 #ater 25 iet soa G5 mil/ 5 one sugar@(ree coo/ie


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pp$!cat!on: Interention, nursing action,ecision or pro'lem that nees to 'earesse

A client is eperiencing a hypoglycemicreaction5 .he nurse aministers #hich 'estitem to the client to treat the reactionH

15 #ater 25 iet soa PG5 mil/ 5 one sugar@(ree coo/ie


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na$)s!s:Consier


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na$)s!s:Consier


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Client Needs

1 Sa(e, e((ectie care enironment

25 7ealth promotion an maintenance

G5 $sychosocial integrity

5 $hysiological integrity


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Client Needs

Sa(e an >((ectie Care >nironment Coorinate Care

Sa(ety an In(ection Control

7ealth $romotion an 4aintenance $sychosocial Integrity

$hysiological Integrity

Basic Care an Com(ort $harmacologic .herapies

Reuction o( Ris/ $otential

$hysiological Aaptation

Clients are de.ined as individuals


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Clients are de.ined as individuals!

.a-ilies and si+ni.icant ot,ers&


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)a.e and E..ective Care

.he practical nurse proies nursing care thatcontri'utes to the enhancement o( the healthcare eliery setting an protects clients anhealth care personnel 'y: Colla'orating #ith health care team

mem'ers to (acilitate e((ectie client care5 Contri'uting to the protection o( clients an

health care personnel (rom health anenironmental ha-ars5

)a.e and E..ective Care Environ-ent0


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Coordinated Care (1D1thical $ractice In(orme Consent In(ormation .echnology


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Coordinated Care contF Legal Responsi'ilities Colla'oration #ith the Interisciplinary .eam Concepts o( 4anagement an Superision

Con(ientialitysta'lishing $riorities $er(ormance Improementucation

) . d E.. ti C E i t


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)a.et and 8n.ection Control (14ternal isaster $lans

&Implementation)

4eical an Surgical Asepsis


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)a.et and 8n.ection Control (14


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Coordinated Care

A client scheule (or surgery tells the nurse that hesigne an in(orme consent 'ut #as neer tol a'out theris/s o( the surgery5 .he nurse seres as the clientsaocate 'y:

15 posting a note on the chart (or the surgeon #ill see it#hen the client arries in the "R5

25 ocumenting in the chart that the client #as not tola'out the ris/s o( the surgery5

G5 noti(ying an RN an re6uesting that the surgeon to 'econtacte an as/e to eplain the surgical ris/s to theclient5

5 reassuring the client that the ris/s are minimal an

unli/ely to occur5


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Coordinated Care

A client scheule (or surgery tells the nurse that hesigne an in(orme consent 'ut #as neer tol a'out theris/s o( the surgery5 .he nurse seres as the clientsaocate 'y:

15 posting a note on the chart (or the surgeon #ill see it#hen the client arries in the "R5

25 ocumenting in the chart that the client #as not tola'out the ris/s o( the surgery5

G5 noti(ying an RN an re6uesting that the surgeon to 'econtacte an as/e to eplain the surgical ris/s to theclient5

5 reassuring the client that the ris/s are minimal an

unli/ely to occur5


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Healt, Pro-otion and 6aintenance

.he practical


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Healt, Pro-otion and 6aintenance (G1


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Healt, Pro-otion and 6aintenance (G1


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Healt, Pro-otion I 6aintenance

A nurse is preparing to care (or a hospitali-eteenager #ho is in s/eletal traction5 .henurse plans care /no#ing that the most li/ely

primary concern o( the teenager is:15 "'taining ae6uate nutrition

25 Boy image

G5 Oeeping up #ith school#or/

5 "'taining ae6uate rest an sleep


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Healt, Pro-otion I 6aintenance

A nurse is preparing to care (or a hospitali-eteenager #ho is in s/eletal traction5 .henurse plans care /no#ing that the most li/ely

primary concern o( the teenager is:15 "'taining ae6uate nutrition

25 Boy image

G5 Oeeping up #ith school#or/

5 "'taining ae6uate rest an sleep


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Psc,osocial 8nte+rit

.he practical


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Psc,osocial 8nte+rit (14


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Psc,osocial 8nte+rit contF

Coping 4echanisms &ienti(ications)

Crisis Interention

Cultural A#areness &consierations o( care)

>n o( Li(e Concepts Qrie( an Loss &assist #ith process)


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4ental 7ealth


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Suicienironment nepecte Boy Image Changes


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A male chil is 'rought to the school nurses o((ice #ith c


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A male chil is 'rought to the school nurses o((ice #ith c


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P,siolo+ic 8nte+rit

.he practical nurse assists in the promotiono( physical health an #ell@'eing 'y proiingcare an com(ort, reucing ris/ potential (orclients an assisting them #ith themanagement o( health alterations 'y:

P,siolo+ic 8nte+rit cont


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P,siolo+ic 8nte+rit contF

$roiing com(ort to clients an assistance in theper(ormance o( their actiities o( aily liing

$roiing care relate to the aministration o(

meications an monitors clients receiingparenteral therapies

Reuces the potential (or clients to eelopcomplications or health pro'lems relate to

treatments, proceures, or eisting conitions $roies care (or clients #ith acute, chronic or

li(e threatening physical health conitions

P, i l i 8 t it


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P,siolo+ic 8nte+rit0

*asic Care and Co-.ort (111Glimination &monitoring patterns)

Assistie eices &canes, crutches, #al/ers, etc)

4o'ility


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*asic Care and Co-.ort

A nurse has proie in(ormation a'out the measuresthat #ill promote normal urination patterns anpreent urinary tract in(ections5 hich statement 'ythe client inicates a nee (or (urther in(ormationH

15 I shoul eat (oos that #ill ma/e my urine aci5!

25 I shoul try to hol my urine in as long as I can ratherthan epelling it #hen I (eel the urge5!

G5 I shoul rin/ plenty o( (luis uring the ay5!5 I shoul ta/e my (urosemie &Lasi) in the morning5!


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*asic Care and Co-.ort

A nurse has proie in(ormation a'out the measuresthat #ill promote normal urination patterns anpreent urinary tract in(ections5 hich statement 'ythe client inicates a nee (or (urther in(ormationH

15 I shoul eat (oos that #ill ma/e my urine aci5!

25 I shoul try to hol my urine in as long as I can ratherthan epelling it #hen I (eel the urge5!

G5 I shoul rin/ plenty o( (luis uring the ay5!5 I shoul ta/e my (urosemie &Lasi) in the morning5!



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P,ar-acolo+ical 2,erapies (;15((ects Contrainications an Compati'ilities osage Calculations

>pecte >((ects 4eication Aministration &; rights) $harmacological Actions $harmacological Agents Sie >((ects Client .eaching

P,siolo+ical 8nte+rit0


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P,ar-acolo+ical 2,erapies contF

Bloo trans(usions &monitoring (or complications)

Counting narcotics


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P,ar-acolo+ical 2,erapies

Cyclosporine &Sanimmune) oral solution isprescri'e (or a client #ho ha a /ineytransplant5 .he nurse proies in(ormation tothe client a'out the meication an tells heclient that #hich o( the (ollo#ing is mostimportant to monitorH

15Apical heart rate

25 $eripheral $ulsesG5 $latelet count

5 .emperature


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P,ar-acolo+ical 2,erapies

Cyclosporine &Sanimmune) oral solution isprescri'e (or a client #ho ha a /ineytransplant5 .he nurse proies in(ormation tothe client a'out the meication an tells heclient that #hich o( the (ollo#ing is mostimportant to monitorH

15Apical heart rate

25 $eripheral $ulsesG5 $latelet count

5 .emperature



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Reduction o. Ris9 Potential (11K


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P,siolo+ical Adaptation (111G


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8nte+rated Processes

.he (ollo#ing processes (unamental to the

practice o( practical


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15 Caring 25 Clinical pro'lem@soling process

G5 Communication an ocumentation

5 .eaching an learning

8 d P


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Car!ng It is ery easy to 'ecome inole #ith the

technological ie#point #hen ans#ering a

6uestionF ho#eer, al#ays thin/ a'out theprocess o( caring #hen ans#ering a 6uestion

8 d P


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Caring 55? interaction o( thepractical


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8nte+rated Processes Carin+

An in(ant is 'rought to the emergency epartment 'yemergency meical serices &>4S) #ith suspectesuen in(ant eath synrome &SIS)5 .he in(antsparents hae accompanie >4S an are present #hen

the in(ant is pronounce ea5 .he most important aspecto( compassionate care (or the parents is to:

15 >plain to the parents that the eath #as not their (ault

25Allo# the parents to say goo'ye to the in(ant5

G5 Qather ata a'out the eents that occurre 'e(ore thein(ant #as (oun

5 >ncourage the parents to atten a support group5

8 d P C i


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8nte+rated Processes Carin+

An in(ant is 'rought to the emergency epartment 'yemergency meical serices &>4S) #ith suspecte suenin(ant eath synrome &SIS)5 .he in(ants parents haeaccompanie >4S an are present #hen the in(ant is

pronounce ea5 .he most important aspect o(compassionate care (or the parents is to:

15 >plain to the parents that the eath #as not their (ault5

25Allo# the parents to say goo'ye to the in(ant5

G5 Qather ata a'out the eents that occurre 'e(ore thein(ant #as (oun

5 >ncourage the parents to atten a support group5



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Clinical Problem-Solving Process(Nursing Process)? a scienti(ic approachto client care that inclues ata collection,planning, implementation an ealuation5

8 t t d P


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C$!n!ca$ 1rob$e So$v!ng &N#rs!ng 1rocess' 15 Data co$$ect!on

Su'8ectie: in(ormation gien 'y the client

"'8ectie: o'sera'le, measura'le 3irst step

I( you are as/e to ienti(y the initial or (irst actionF

(ollo# the steps o( the nursing process, i( a atacollection action is one o( the options, that option ismost li/ely correct

I( the 6uestion aresses an emergency situation,

rea care(ullyF an interention may 'e the priority

8nte+rated Processes0


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ata CollectionA postoperatie as/s the nurse (or pain

meication5 .he nurse shoul ta/e #hich action(irstH

15As/ the client ho# long it has 'een since the lastose o( pain meication #as aministere5

25 Qather ata (rom the client a'out the pain

G5 $repare the prescri'e ose o( pain meication

5As/ the client i( the last ose o( the meication#as e((ectie5



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ata CollectionA postoperatie client as/s the nurse (or pain

meication5 .he nurse shoul ta/e #hich action(irstH

15As/ the client ho# long it has 'een since the lastose o( pain meication #as aministere5

25 Qather ata (rom the client a'out the pain

G5 $repare the prescri'e ose o( pain meication

5As/ the client i( the last ose o( the meication#as e((ectie5

8 t t d P


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C$!n!ca$ 1rob$e So$v!ng 25 1$ann!ng

Setting priorities

Assisting in etermining goals


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8nte+rated Processes0 Plannin+

A nurse is reie#ing the nursing iagnoses #ritten ina nursing care plan (or a client #ith chronico'structie pulmonary isease5 .he nurse eterminesthat #hich nursing iagnosis is the priorityH

15 Ine((ectie Role $er(ormance r


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8nte+rated Processes0 Plannin+

A nurse is reie#ing the nursing iagnoses #ritten ina nursing care plan (or a client #ith chronico'structie pulmonary isease5 .he nurse eterminesthat #hich nursing iagnosis is the priorityH

15 Ine((ectie Role $er(ormance r


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C$!n!ca$ 1rob$e So$v!ng G5 Ip$eentat!on

Client in test 6uestion is your only assigne

client Client in test 6uestion is only client you are

concerne a'out

Ans#er 6uestion (rom tet'oo/


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8-ple-entation A nurse is assisting in monitoring a client (ollo#ing a

cariac catheteri-ation proceure5 .he client suenlycomplains o( a (eeling o( #etness at the in8ection site5.he nurse 6uic/ly chec/s the site an iscoers that the

client is 'leeing5 .he 'est initial nursing action is to:15 Apply (irm pressure to the site using a sterile gau-e

pa5

25 Apply (irm pressure to the site using a 'ath to#el5

G5 As/ the client to place pressure on the site5

5 Chec/ the clients 'loo pressure



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8-ple-entation A nurse is assisting in monitoring a client (ollo#ing a

cariac catheteri-ation proceure5 .he client suenlycomplains o( a (eeling o( #etness at the in8ection site5.he nurse 6uic/ly chec/s the site an iscoers that the

client is 'leeing5 .he 'est initial nursing action is to:15 Apply (irm pressure to the site using a sterile gau-e

pa5

25 Apply (irm pressure to the site using a 'ath to#el5

G5 As/ the client to place pressure on the site5

5 Chec/ the clients 'loo pressure



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C$!n!ca$ 1rob$e So$v!ng 5 Eva$#at!on

"ngoing, continual process o( comparingactual #ith epecte outcomes

$roies means (or etermining nee tomoi(y plan o( care

3re6uently #ritten in (alse response (ormatFie the 6uestion may as/ (or a clientstatement that inicates inaccuratein(ormation relate to the issue o( the6uestion

8nte+rated Processes0 Evaluation


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I'upro(en &4otrin) has 'een prescri'e (or aclient5 "n a (ollo#@up physicians isit, thenurse etermines that the meication ise((ectie i( the client states relie( o(:

15A'ominal 'loating

25 Constipation5

G5 oint sti((ness5

5 7eart'urn5



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I'upro(en &4otrin) has 'een prescri'e (or aclient5 "n a (ollo#@up physicians isit, thenurse etermines that the meication ise((ectie i( the client states relie( o(:

15A'ominal 'loating5

25 Constipation5

G5 oint sti((ness5

5 7eart'urn5



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Communication and Documentation?er'al an noner'al interactions 'et#een

the practical


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Co#n!cat!on .herapeutic communication techni6ues

inicate a correct option

Nontherapeutic communication techni6uesinicate an incorrect response

I( an option re(lects a clients (eelings,anieties, or concerns, select that option



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+

Co--unicationA client says to a nurse, Im scare a'out my

surgery that I am haing tomorro#5! .he nursema/es #hich appropriate response to the clientH

15 .here is no reason to 'e scare5!

25 +ou hae plenty o( reasons to 'e scare5Surgery is a scary thing5!

G5 ScareH!

5 4ost people #ho hae to hae surgery arescare5!



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+

Co--unicationA client says to a nurse, Im scare a'out my

surgery that I am haing tomorro#5! .he nursema/es #hich appropriate response to the clientH

15 .here is no reason to 'e scare5!

25 +ou hae plenty o( reasons to 'e scare5Surgery is a scary thing5!

G5 ScareH!

5 4ost people #ho hae to hae surgery arescare5!



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Doc#entat!on Reie# ocumentation guielines@legal an ethical Sample 6uestion:

A nurse iscoers that she nees to ma/e a correction to

a #ritten entry in a clients chart5 .he nurse #oulappropriately:

1) Contact the nursing superisor to cosign thecorrection

2) Remoe the page, recopy the ata to a ne# page,

an a the correct entryG) ra# a single line through the entry that nees

correction (ollo#e 'y hisrase the entry that nees correction an a the

correct entry


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Sample 6uestion: A nurse iscoers that she nees to ma/e a

correction to a #ritten entry in a clients chart5 .henurse #oul appropriately:

1) Contact the nursing superisor to cosign thecorrection

2) Remoe the page, recopy the ata to a ne#page, an a the correct entry

G) ra# a single line through the entry that nees

correction (ollo#e 'y hisrase the entry that nees correction an a

the correct entry



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Teaching and Learning 55? (acilitation o(the ac6uisition o( /no#lege, s/ills anattitues to assist in promoting positie

changes in 'ehaior



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(each!ng an Learn!ng I( a test 6uestion aresses client teaching,

remem'er that client motiation an

reainess to learn is the 3IRS. priority See hanout



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+

2eac,in+ I Learnin+

A nurse has rein(orce teaching #ith a clients spouse a'outho# to change the clients colostomy 'ag5 .he nurse 'estetermines that the spouse unerstans the proceure 'y:

15As/ing the spouse i( she has any 6uestions a'out theproceure5

25As/ing the spouse is she unerstans #hat items areneee to per(orm the proceure5

G5As/ing the spouse to per(orm the proceure an o'sereher per(orming it5

5As/ing the spouse is she (eels com(orta'le per(orming theproceure5



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+

2eac,in+ I Learnin+

A nurse has rein(orce teaching #ith a clientsspouse a'out ho# to change the clients colostomy'ag5 .he nurse 'est etermines that the spouseunerstans the proceure 'y:

15As/ing the spouse i( she has any 6uestions a'outthe proceure5

25As/ing the spouse is she unerstans #hat itemsare neee to per(orm the proceure5

G5As/ing the spouse to per(orm the proceure ano'sere her per(orming it5

5As/ing the spouse is she (eels com(orta'le

per(orming the proceure

2pes o. 2est uestions


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2pes o. 2est uestions

4ultiple Choice &ma8ority J=@0) "nly onecorrect ans#er

3ill in the 'lan/ Numerical response &6uestion #ill tell you ho# to

roun your ans#er an #hat units) 4ultiple response &must hae all correct ans#ers to

receie creit) =@; potential ans#er choices

$rioriti-ing &"rere response) 3igure or illustration &hot spot) Chart


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7ill in t,e *lan9

.he nurse is preparing to aminister igoin&Lanoin) 052=mg orally5 .he la'el on themeication 'ottle reas igoin &Lanoin)0512= mg per ta'let5 7o# many ta'let&s) oesthe nurse plan to aminister to the clientH&roun to the nearest 05=)

ta'let&s)

6ultiple Response


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6ultiple Response

Select all nursing interentions that apply in the careo( an in(ant (ollo#ing a cle(t lip repair &cheiloplasty)

$osition the chil on the a'omen

Cleanse the suture line gently a(ter (eeing the in(ant

Oeep el'o# restraints on the in(ant at all times

Institute measures that #ill preent igorous ansustaine crying

"'sere (or 'leeing at the operatie siteAssist the mother #ith 'reast(eeing i( this is the

(eeing metho o( choice

sin+ a 7i+ure or 8llustration


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sin+ a 7i+ure or 8llustration

.he nurse is per(orming C$R on a ; monthol in(ant5 sing the computer mouse, clic/on the anatomical area that the nurse #oulpalpate to assess circulation5


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###5atitesting5com http:


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PrioritiMin+

List in orer o( priority the interentions thatthe nurse #oul ta/e in the care o( a client#ho eelops acute pulmonary eema5&Num'er 1 inicates the (irst action annum'er inicate the last action5)

$lace the client on pulse oimetry

$lace the client in high@3o#lers position

$repare the client (or enotracheal intu'ationan mechanical entilation

$repare (or the aministration o( oygen

sin+ a C,art or E/,i%ition


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sin+ a C,art or E/,i%ition

.he nurse reie#s theclients la'oratoryresults (or electrolyteleels5 .he nurse

reports #hicha'normal resultH

15 Soium

25 $otassium

G5 Chlorie5 Bicar'onate

Clients Chart

4es NotesLa's

Soium1=0m>666


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6ultiple C,oice

Ienti(y parts o( the 6uestion Rea care(ully

Loo/ (or /ey #ors or phrases

Ienti(y the issue se the process o( elimination

Aoi as/ing yoursel( hat i(H!

Parts o. t,e uestion


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Parts o. t,e uestion

15 Case s!t#at!on, .he heart o( the 6uestionFproies #ith in(ormation neee to ans#er

25 6#est!on ste,Statement that generally(ollo#s the situation an as/s something eryspeci(ic a'out the in(o in the case situation

G5 7pt!ons,All ans#ers presente #ith the6uestion &usually )

e Bords'P,rases


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e Bords'P,rases

3ocus your attention on critical an speci(icpoints

4ay inicate there is only one option

4ay inicate you may nee to prioriti-e 4ay inicate a true response 6uestion

4ay inicate a (alse response 6uestion

e Bords or P,rases 2,atF


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In!cate there !s onlyonecorrect opt!on

>arly sign

Late sign

nerstans

Qoal has 'eenachiee

Ae6uately toleratingAoi

Nees rein(orcement

o( the instructions

Lac/ o(unerstaning

Qoals hae not yet'een (ully met

7as not met theoutcome criteria

Ine((ectie Inae6uate na'le to tolerate



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In!cate the nee topr!or!t!8e

Best

3irst Initial

Immeiately

4ost or least li/ely 4ost or least

appropriate

7ighest or lo#estpriority

"rer o( priority

At highest ris/

At lo#est ris/

Best unerstaning



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In!cate a tr#eresponse

>arly sign Late sign

Best 3irst Last Initial

Immeiately4ost li/ely4ost appropriate

7ighest priority

"rer o( priority

All nursinginterentions thatapply

Qoal has 'eenachiee

Ae6uatelytolerating



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In!cate a falseresponse

Least li/ely Least appropriate

Least priority Least help(ulAt lo#est ris/AoiNees

rein(orcement o( theinstructions

Nees aitionalteaching

Lac/ o(

unerstaning Qoals hae not yet

'een (ully met 7as not met the

outcome criteria Ine((ectie Inae6uate na'le to tolerate

2,e 8ssue o. t,e uestion


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e ssue o e ues o

Speci(ic su'8ect content that the 6uestion isas/ing a'out

Loo/ 'ac/ at the Client Nees

2,e 8ssue o. t,e uestion


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Sample Kuestion A client #ith metastatic cancer is receiing

morphine sul(ate to alleiate pain5 .henurse monitors the client (or #hich aerse

or toic e((ect o( the meicationH

15 i--iness

25 Seation

G5 S/eletal muscle (lacciity5 Nausea

Rando- )trate+ies


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+

$rocess o( elimination Li/ely to eliminate t#o o( the optionsF you

hae t#o remaining

ith those t#o remaining: Rea the 6uestion again

Ienti(y the case situation

Loo/ (or /ey #ors


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Sample 6uestion A nurse is caring (or a hospitali-e client #ith a

iagnosis o( congestie heart (ailure #hosuenly complains o( shortness o( 'reath an

yspnea5 .he nurse ta/es #hich immeiateactionH

1) $repares to aminister (urosemie &lasi)

2) Calls a respiratory therapistG) $repares to aminister oygen

) >leates the hea o( the clients 'e

PrioritiMin+ uestions


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+

Qeneral Quielines Note /ey #ors


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+

Best >ssential 3irst

7ighest priority Immeiately Initial 4ost appropriate 4ost e((ectie

4ost important 4ost li/ely

Nest

"rer o( priority $riority

$rimary

%ital

6aslows Hierarc,


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6aslows Hierarc, o. Needs 2,eor


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A nurse is assisting #ith the amission o( aclient to the mental health unit #ith aiagnosis o( post@traumatic stress isorer5.he client is con(use an isoriente5

uring the ata collection, the nursesprimary goal (or this client is to:

15 Sta'ili-e the clients psychiatric nees

25 "rient the client to the unitG5 >plain the unit rules

5 4a/e the client (eel sa(e

6aslows


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A nurse has helpe eelop a plan o( care(or a client iagnose #ith anoreia nerosa5hich nursing iagnosis #oul the nurseselect as the priority in the plan o( careH

15 istur'e Boy Image

25 e(ensie Coping

G5 e(icient Ono#lege

5 Im'alance Nutrition: Less .han BoyRe6uirements

6aslows


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A nurse is preparing to rein(orce instructions #ith aclient a'out using crutches5 Be(ore rein(orcingthe instructions, the nurse collects #hichpriority in(ormation (rom the clientH

15 .he clients (ear relate to the use o( crutches

25 .he clients unerstaning o( the nee (orincrease mo'ility

G5 .he clients muscle strength an preiousactiity leel

5 .he clients (eelings a'out the restricte actiity

PrioritiMin+ uestions


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+

!ghest 1r!or!t):A client nee that is li(e@threatening or i( untreate coul result inharm to the client

Intere!ate 1r!or!t):Non@emergency or

non li(e@threatening client nee that oes notre6uire immeiate attention

Low 1r!or!t):Client nee that is not irectlyrelate to the clients illness or prognosis, is

not urgent or oes not re6uire immeiateattention

PrioritiMin+


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+

A nurse is caring (or a client #ith anginapectoris #ho 'egins to eperience chestpain5 .he nurse aministers a su'lingualnitroglycerin &Nitrostat) ta'let as prescri'e,

'ut the pain is unreliee5 hat actionshoul the nurse ta/e netH

15 Call a Coe Blue

25 Call the clients (amilyG5 Aminister another nitroglycerin ta'let

5 Reposition the client

PrioritiMin+


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+

An in(ant #ith tetralogy o( 3allot eperiencesa hypercyanotic spell uring a 'loo ra#5List in orer o( priority the actions that thenurse #oul ta/e &num'er one is the (irst

priority an num'er (our is the lo#est priority)5Aminister morphine sul(ate su'cutaneously

as prescri'e

Aminister 100 oygen 'y (ace mas/ as

prescri'e$lace the in(ant in a /nee@chest position

Aminister intraenous (luis as prescri'e

2,e A*Cs


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.he client #ith a iagnosis o( cancer isreceiing morphine sul(ate 10 mgsu'cutaneously eery G to hours (or pain5hen preparing a plan o( care (or the client,

the nurse inclues #hich priority actionH15 4onitor stools

25 4onitor the urine output

G5 >ncourage the client to cough an eep'reathe

5 >ncourage (lui inta/e

2,e A*Cs


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A nurse is monitoring a clients conitiona(ter carioersion5 hich o( the (ollo#ingo'serations is the highest priority to thenurseH

15 Status o( air#ay

25 "ygen (lo# rate

G5 Leel o( consciousness

5 Bloo pressure

2,e A*Cs


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A nurse is rein(orcing preoperatieinstructions to a client scheule (or acholecystectomy5 hich interention is o(the highest priority in the preoperatie

teaching planH

15 .eaching coughing an eep 'reathingeercises

25 .eaching leg eercisesG5 Instructing regaring (lui restrictions

5 etermining the clients unerstaning o( the

surgical proceure

B,en to )elect =Noti. an RN>


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I( the 6uestion ">S N". escri'e a li(e@threatening client situation or one that inicates achange in the clients conition AN there is anoption that irectly relates to a nursing actionreleant to the situation, then it 'est to select thatoption an N". the option that reas Notify theRN

I( the 6uestion ">S escri'e a li(e threatening

client situation or one that inicates a change inclients conition, then select the option that reasNotify the RN

Noti. RN:


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A nurse is caring (or a postoperatie client#ho 'ecomes restless5 .he nurse shoulta/e #hich initial actionH

15 Chec/ the clients ital signs

25 Noti(y a registere nurse

G5 4eicate the client (or pain

5 .al/ to the client in a calm oice

Noti. RN:


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A nurse is caring (or a client #ho 8ust returne(rom the recoery room (ollo#ing atonsillectomy an anoiectomy5 .he client isrestless an the pulse rate is eleate5 .he

nurse prepares to collect aitional ata onthe client 'ut the client 'egins to omit largeamounts o( 'right re 'loo5 .he immeiatenursing action is to:

15 Noti(y an RN25 Continue #ith ata collection

G5 Chec/ the clients 'loo pressure

5 "'tain a (lashlight an gau-e

e Bords 2,at 8ndicateF


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ata Collection Chec/

Collect

etermine 3in out

Qather

Ienti(y 4onitor

"'sere

"'tain In(ormation

ata Collection


146/186

A nurse is teaching a client #ith coronaryartery isease a'out ietary measures to(ollo#5 uring the session, the clientepresses (rustration in learning the ietary

regimen5 .he nurse shoul initially:15 Ienti(y the cause o( (rustration

25 Continue #ith the ietary teaching

G5 Noti(y a registere nurse

5 .ell the client that the iet nees to 'e(ollo#e

Plannin+


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A nurse is reie#ing the plan o( care (or apregnant client #ith a iagnosis o( sic/le cellanemia5 hich nursing iagnosis, i( stateon the plan o( care, shoul the nurse select

as receiing the highest priorityH

15 Aniety

25 Ine((ectie coping

G5 istur'e 'oy image5 e(icient (lui olume

8-ple-entation


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ANS!" T#! $%!ST&'N "' AN &D!ALT!*T+'', P!"SP!CT&!. /'% #A!

ALL T#! T&! AA&LA+L! T' CA"! '"

T#! CL&!NT AND ALL T#! "!S'%"C!S

AT T#! CL&!NT0S +!DS&D!1

8-ple-entation


149/186

A nurse is caring (or a preoperatie male client #hoer'ali-es a great eal o( aniety a'out the surgicalproceure scheule in t#o hours5 hich action 'y thenurse #oul 'est alleiate the clients anietyH

15 .ell the client that you #ill spen some time ans#ering

6uestion as soon as you get your other tas/s complete25 .al/ to the client (or 1= minutes an return shortly

therea(ter to chec/ on him

G5 Call the clients #i(e an as/ her to isit the client 'e(ore

surgery5 Stay #ith the client until he is ta/en to the operating room

8-ple-entation


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A nurse is caring (or a client (ollo#ing a cariaccatheteri-ation5 .he client suenly complains o( a(eeling o( #etness in the groin at the catheterinsertion site5 .he nurse chec/s the site, notes thatthe client is actiely 'leeing, an ta/es #hich 'est

actionH15 on a clean gloe an places pressure on the

insertion site #ith the gloe han

25 ons a sterile gloe an places pressure on the

insertion site using sterile gau-eG5 Chec/s the clients 'loo pressure

5 Chec/s the clients peripheral pulse in the a((ecteetremity

Evaluation


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A client recoering (rom an eacer'ation o( le(t@sie heart(ailure has a nursing iagnosis o( Actiity Intolerance5.he nurse etermines that the client 'est tolerates mileercise i( the client ehi'its #hich o( the (ollo#ingchanges in ital signs uring actiityH

15 $ulse rate increase (rom J0 'eats


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uestions

Al#ays ensure client sa(ety 4atch tas/s 'ase on Nurse $ractice Act

.hin/ a'out iniiual ariations in #or/

a'ilitiesAl#ays proie clear irection to the

elegatee

Oeneral Ouidelines0 B,o Can o

B,at


153/186

B,at

A$Am'ulation Bathing Qrooming 7ygiene measures $ositioning R"4 eercises

S/in care Some specimen collection &urine, stool) .ransporting a client


B,at


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B,at

L$NAll that A$ can o AN

Aministering $" mes

Aministering I4 mesAministering SK mes

ressing changes

Irrigating #ouns


B,at


155/186

B,atL$N &continue)

4onitoring I% (lo# rate

$er(orming urinary catheteri-ation

Suctioning .eaching a'out 'asic hygiene


156/186

B,at

RN can oALL that A$ an L$N can o AN

Aminister I% meications

Leaing others an managing client careenironment

.eaching

sing nursing process: assessment,analy-ing ata, planning client care,implementing an ealuating care

ele+ation'Assi+n-ents


157/186

A license practical nurse is planning client assignments (orthe ay an has another license practical nurse an anursing assistant on the nursing team5 .he nurse mostappropriately assigns #hich client to the licensepractical nurseH

15 An oler client recoering (rom pneumonia #ho re6uiresam'ulation eery G hours

25 A client #ith a tracheostomy #ho re6uires (re6uentsuctioning

G5 An oler client #ho re6uires turning an repositioningeery 2 hours an range o( motion eercises eery hours

5 A client #ho re6uires the collection o( urine (or a 2@hourperio

ele+ation'Assi+n-ents


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A license practical nurse employe in a long termcare (acility is assigning client care actiities to anursing assistant5 .he nursing assistant is a (irst@semester senior nursing stuent an #or/s at the(acility as a nursing assistant part@time on #ee/@ens5 .he (acility position escription (or a nursingstuent #ho is employe as a nursing assistantinicates that he or she may per(orm proceureslearne in nursing school i( superise 'y a licensenurse5 Base on the (acilitys position escription,the nurse assigns #hich most appropriate actiity to

the nursing assistantH15 7ang an I% solution o( 05 normal saline25 Insert an I% catheterG5 Change a sterile a'ominal ressing5 Aminister igoin &Lanoin)

2i-e 6ana+e-ent


159/186

4ust o Shoul o

Nice to o

3ocus on 'eginning the aily tas/s, #or/ingon the most important (irst #hile /eepinggoals in min

.hin/

"rgani-e

$lan

$rioriti-e

2i-e -ana+e-ent


160/186

A nurse on the ay shi(t is assigne to care (or the (ourclients5 3ollo#ing report (rom the night shi(t, the nurseplans to per(orm client rouns an collect ata (rom eachclient5 Num'er in orer o( priority ho# the nurse #ill planthe client rouns5 &Num'er 1 is the (irst client that the

nurse #ill chec/ an collect ata (rom an num'er isthe last client that the nurse #ill chec/ an collect ata(rom5)

Client scheule (or a cariac catheteri-ation at 11 am

Client iagnose #ith ia'etes mellitus #ho is scheule(or ischarge to home at 12 noon

Client #ith emphysema #ho is receiing oygen therapy

Client scheule to hae an electrocariogram &>CQ) at2:00 pm

Co--unication uestions


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4ay 'e in any clinical setting an in anypatient care areaE

3ocus on clients (eelings, concerns, anietiesor (ears

Consier cultural i((erences: communicationstyles, use o( eye contact, meaning o( touch

Nontherapeutic techni6ues impee or 'loc/

the (lo# o( communicationF shut o#n or shuto(( conersation

P,ar-acolo+ical uestions


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4eication Rights Al#ays :

Chec/ (or allergies hypersensitiities

As/ the client a'out eisting meical isorers that are

contrainicate #ith the aministration o( a prescri'eme

Chec/ (or potential interactions relate to the me

Chec/ pertinent la' alues

Chec/ ital signs, particularly i(antihypertensie


163/186

Intene e((ect: esire e((ect

Sie e((ect: Not a esire e((ect

Not usually li(e@threatening

Can usually 'e alleiate #ith speci(ic measures

Aerse e((ect: more seere than a sie e((ectAl#ays an unesira'le e((ect

Al#ays reporte to an RN an 4

.oic e((ect: 4eication leel in the 'oy eceesthe therapeutic leel

.ylenol, .egretol5 Lanoin, Qentamycin, Lithium,4agnesium sul(ate, ilantin, Salicylate,

.heophylline

P,ar-acolo+ical uestions


164/186

Re(er to 3"N Appeni C pg 12J1

Loo/ to the trae name


165/186

.he nurse notes that a physician hasprescri'e cotrimoa-ole &Bactrim) (or aclient #ith a urinary tract in(ection5 hichpriority action #ill the nurse ta/e 'e(ore

aministering this meicationH15 Call the pharmacy to orer the meication

25 As/ the client a'out an allergy tosul(onamies

G5 Chec/ the meication supply room to (in outi( the meication nees to 'e orere

5 In(orm the client a'out the nee to increase(lui inta/e

P,ar-acolo+


166/186

A client ta/ing amitriptyline hyrochlorie&>lail) calls the nurse at the physicianso((ice an reports that he eelops an upsetstomach #heneer he ta/es the meication5

.he nurse appropriately tells the client to:15 .a/e the meication #ith an antaci

25 Stop the meication (or 2 ays an thenresume the prescri'e meication scheule

G5 .a/e the meication on an empty stomach5 .a/e the meication #ith (oo

osa+e Calculations


167/186

.otal %olume D gtt 3actor.ime in minutes

Aaila'le mg esire mg Aaila'le mLP esire mLP

mL


168/186

se the on@screen calculator Conert the unit o( measure is necessary 3ollo# the (ormula $lace the ecimal points in the correct places $lace a -ero 'e(ore a ecimal point i( the

alue lac/s a num'er 'e(ore the ecimalpoint &05= not 5=)

Aoi placing a ecimal point an a -ero a(tera #hole num'er &= not =50) Rechec/ the accuracy o( the calculationEE

osa+e Calculations


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A physicians orer reas phenytoin&ilantin) 052 g orally t#ice aily5 .hemeication la'el states 100 mg capsules5 Anurse prepares ho# many capsule&s) to

aminister one oseH15 1 capsule

25 2 capsules

G5 G capsules5 capsules

osa+e Calculations


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A physician orers 1000mL o( one@hal(normal saline to in(use oer J hours5 .herop (actor is 1= rops &gtt) per 1 mL5 .henurse sets the (lo# rate at ho# many rops

per minuteH &roun to the nearest #holenum'er)

15 1J rops per minute

25 G1 rops per minute

G5 rops per minute5 100 rops per minute

Additional Oeneral )trate+ies0

A%solute Bords


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A'soluteAll

Al#ays

Cant

>ery

4ust

Neer

None Not

"nly

ont

Not@So@A'solute ors Qenerally

4ay

$ossi'ly

sually

In genera$+ !% anopt!on conta!ns an

abso$#te wor+ !t !s!ncorrect

A%solute Bords


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A nurse is proiing ietary instructions to aclient a'out a lo#@(at iet5 .he nurse tellsthe client to:

15 Neer use 'utter in their coo/ing

25 Rea the la'els on (oo items to eterminetheir (at content

G5 >at only (oos that hae less than 1 (at

content5 rin/ (luis only i( they are (at (ree

Not)oA%solute Bords


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A client scheule (or a computetomography &C.) scan o( the a'omen as/sthe nurse #hen the results o( the test #ill 'eaaila'le5 .he nurse ma/e #hich appropriate

response to the clientH15 .he results #ont 'e aaila'le (or at least

one #ee/!

25 +ou must as/ the C. technician (or that

in(ormationG5 +our physician may hae the results in a'out

G ays

5 >ery scan is rea 'y a raiologist an thisprocess al#ays ta/es 1 #ee/

Additional Oeneral )trate+ies0 6edical

vs Nursin+ 8nterventions


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+

Select the option that is a nursing interentionan not a meical one

.he only situation in #hich you may nee toselect a meical interention is i( the 6uestion

inicates to o so, i5e5 hich interentionoes the nurse anticipate the physician #illprescri'eH!

Eli-inatin+ ptions 2,at Contain 6edical

Rat,er 2,an Nursin+ 8nterventions


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A nurse is caring (or a client #ith a iagnosiso( congestie heart (ailure #ho suenlyeperiences seere yspnea, an the nursesuspects that the client eelope

pulmonary eema5 .he nurse immeiately:15 "'tains a ial o( (urosemie &Lasi) an a

syringe

25 $laces the client in the high@3o#lers position

G5 "'tains a ose o( morphine sul(ate (rom thenarcotic meication ra#er

5 Inserts a (oley catheter


Eli-inatin+ )i-ilar ptions


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Note options that are similar in regars totheir content or contetF i( they are present,they are 'oth #rongUmultiple choice6uestions hae only "N> right ans#er

Additional Oeneral Ouidelines0

All Parts o. an ption are Correct


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2 part ans#ers: connecte 'y an! or! Both must 'e correct

.he nurse epects to collect the (ollo#ing ataon a client #ith a cataract o( the right eye: 15 Complaints o( 'lurre ision AN ecessie

tearing o( the eye 25 A clouy #hite pupil AN complaints o( eye

pain G5 Complaints o( a graual loss o( ision AN

photopho'ia 5 Complaints o( a (rontal heaache AN

photopho'ia

Additional Oeneral Ouidelines

)elect t,e -%rella ption


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Qeneral statement that may incorporate thecontent o( the other options #ith it

hen you are ans#ering a 6uestion an notethat more than one option appears to 'e

correct, L""O 3"R .7> 4BR>LLA"$.I"N

-%rella ption


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Sample 6uestion A nurse in the emergency epartment receies a

phone call (rom >4S an is tol that seeral ictims#ho surie a plane crash an are su((ering (romcol eposure #ill 'e transporte to the hospital5 .he

initial nursing action is #hich o( the (ollo#ingH1) Supply the trauma rooms #ith 'ottles o( sterile #ater

an normal saline

2) Call the launry epartment an as/ to sen asmany #arm 'lan/ets as possi'le to the emergency

epartmentG) Call the nursing superisor to actiate the agency

isaster plan

) Call the IC to re6uest that nurses 'e sent to theemergency epartment

Additional Oeneral Ouidelines0

isualiMe t,e 8n.or-ation


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3orm a mental image o( the situation an placeyoursel( into the situation

isualiMin+


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Sample 6uestion A nurse prepares to per(orm a sterile

ressing change on a $ICC line5 .he nurseeplains the proceure to the client, #ashes

her hans, an sets up the sterile (iel5 .henurse #oul ta/e #hich action netH1) on sterile gloes

2) on clean gloes an remoe the ol ressing

G) Clean the site #ith Chloraprep

) Inspect the integrity o( the s/in aroun theinsertion site


)i-ilar Concepts


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Loo/ (or similar concepts in the 6uestion anin one o( the options

Sample 6uestion A client is amitte to the hospital #ith a

iagnosis o( pericaritis5 A nurse monitorsthe client (or #hich mani(estation thati((erentiates pericaritis (rom othercariopulmonary pro'lemsH

1) Chest pain that #orsens on inspiration

2) $ericarial (riction ru'

G) Anterior chest pain

)

ea/ness an irrita'ility

La%orator alues


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Ienti(y #hether the la'oratory alue isnormal or a'normal

Note the isorer presente in the 6uestion

Ienti(y the associate 'oy organ that isa((ecte as a result o( the isorer

La%orator alues


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A client #ith a iagnosis o( sepsis isreceiing anti'iotics 'y the intraenousroute5 .he nurse monitors (or nephrotoicity'y chec/ing the results o( #hich la'oratory

alue most closelyH15 Bloo urea nitrogen

25 hite 'loo cell count

G5 $latelet count5 Lipase leel


Client Positionin+


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Al#ays reie# physician orers 3ocus on clients iagnosis

Ienti(y the anatomical location o( the clientsiagnosis

Consier the pathophysiology o( the isoreran the goals o( care

.hin/ a'out #hat complications you #ant to

preent See hanout

Client Positionin+


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A nurse assists a physician in per(orming alier 'iopsy5 A(ter the 'iopsy, the nurse plansto place the client in #hich o( the (ollo#ingpositionsH

15 Supine

25 $rone

G5 A le(t sie@lying position #ith a small pillo# or

( l t l th t it

Pn 154 Nclex Review

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Transcript of Pn 154 Nclex Review