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NCLEX RN Exam Answers

When selecting an NCLEX answer or determining the order of priority what should you remember or use and what is the exception?

Use the ABC rule: airway breathing and circulation. The exception to the rule is with actual CPR; use C-A-B for CPR. Also, remember safety first and acute before chronic. If the patient is not in distress, then you assess.

If the patient is in distress, then you should do something. If the patient has diaphoresis, you should always do something.

How should you address questions related to Maslow’s Hierarchy of Needs.

Address physiological needs first, followed by safety and security, love and belonging, self-esteem, and finally self-actualization needs.

When the question does not address a physiological need, look for an option that addresses safety.

If a question is related to the nursing process, read the question to determine the step of the nursing process. What are the steps in the nursing process and what kind of question might be related to that step.

Assessment question address the gathering and verification of data.

Analysis questions require the nurse to: interpret data, collect additional information, identify and communicate nursing diagnoses and determine the health team’s ability to meet the pts needs.

Planning questions ask about determining, prioritizing, and modifying outcomes of care.

Implementation questions reflect the management and organization of care and the assignment and delegation of tasks. Be prepared for questions on client teaching.

Evaluation questions focus on comparing the actual care outcomes with the expected outcomes and communicating and documenting findings.

ParameterNormal RangesSpecificsFactors Increasing ValuesFactors Decreasing ValuesAdditional Information
Hemoglobin (H&H)Male: 14-18
Female: 12-16
Newborn: 14-24
High altitude living increases value,
slight decrease during pregnancy.
Drug therapy can alter values.
HematocritMale: 42-52
Female: 37-47
Newborn: 44-64
Prolonged stasis from vasoconstriction secondary to the tourniquet can alter values.
Abnormalities in RBC size may alter Hct values.
WBCBoth genders: 5000-10000
Newborn: 9000-30000
Anesthetics, stress, exercise, and convulsions.Drug therapy.24-28 hr postpartum: a count as high as 25000 is normal.
RBCMales: 4.7-6.1 million
Female: 4.2-5.4 million
Exercise and high altitudes can cause an increase levels.
Pregnancy usually lower values.
Drug therapy can alter values.
Never draw a specimen from an arm with an infusing IV.
PlateletsBoth Genders: 150000-400000Living at high altitudes, exercising strenuously or taking oral contraceptives.Decreased values may be caused by hemorrhage, DIC, reduced production of platelets, infections, use of prosthetic heart valves, and drugs.Drugs that decrease platelets: acetaminophen, aspirin, chemotherapy, H2 blockers, INH, Levaquin, streptomycin, sulfonamides, thiazide diuretics.
K+ (Potassium)3.5-5Exercise of the forearm with tourniquet in place may cause an increased level.
Hemolysis of specimen can result in a falsely elevated value.
Na+ (Sodium)136-145Do Not collect from an arm with an infusing IV solution.

What are the normal ranges for Ca+?
What type of drug can increase calcium levels?
What are two tests with positive results that are associated with hypocalcemia?
How do you preform the two tests?

  • 9-10.5 for adults, slightly lower in the elderly. The use of thiazide diuretics can increase calcium levels.
  • Positive Chvostek and Trousseau tests are associated with hypocalcemia.
  • Chvostek sign: contraction of ipsilateral facial muscles when the facial nerve is tapped just in front of the ear.
  • Trousseau sign: carpopedal spasm elicited by inflating a sphygmomanometer above systolic BP for 3 minutes.
What are the normal ranges for Mg+?
What may high magnesium levels indicate?
What may low magnesium levels indicate?

A high magnesium level may indicate: Addison disease
Chronic renal failure, Dehydration, Diabetic acidosis

A low magnesium level may indicate: Alcoholism
Chronic diarrhea, Delirium tremens, Hemodialysis
Hepatic (liver) cirrhosis, Hyperaldosteronism
Hypoparathyroidism, Pancreatitis, Too much insulin
Toxemia of pregnancy, Ulcerative colitis
What are the normal ranges for Cl-98-106 is the normal range for chloride
What are the normal ranges for ALP (alkaline phosphatase)?30-120
slightly increased in the elderly
What are the normal ranges for BUN?
What does BUN stand for?
What is the ratio of BUN-creatinine?
What does it indicate?
blood urea nitrogen
BUN-creatinine ratio of 20:1 indicates adequate kidney functioning
What are the normal ranges for Creatinine?
What is the ratio of BUN-creatinine?
What does it indicate?
Male 0.6-1.2
Female 0.5-1.1
BUN-creatinine ratio of 20:1 indicates adequate kidney functioning
What is the relationship of Ca+ and PO4?
What is the relationship of Ca+ and pH?
calcium and phosphorus have an inverse relationship: when calcium levels increase, phosphorus levels decrease, and vice versa.
pH also affects the level of ionized calcium:
As pH rises and blood becomes more alkalotic, calcium binds more easily with protein, causing the level of ionized calcium to drop.
Conversely, when pH falls, causing acidosis, less calcium binds with protein, which raises the ionized calcium level
What are the normal ranges for ABGs?
(pH, pCO2, HCO3)
pH (AC) 7.35-7.45 (AL)
pCo2 (AL) 35 – 45 (AC)
HCO3 (AC) 22 – 26 (AL)
What are the normal ranges for PT? What is PT used to help regulate? What is the therapeutic range?11-12.5 is a normal PT range
PT is used to help regulate Coumadin dosages. The therapeutic range: 1.5 to 2 times normal or control
What are the normal ranges for INR?
What type of patients should have individualized values
What should the values be for those patients?
0.8-1.1 normal INR
Individualized values for pts with:
Afib and DVT between 2.0 and 3.0
mechanical heart valves between 3.0 to 4.0
What are the normal ranges for PTT and aPTT? What do they help regulate? What is the therapeutic range?normal range PTT: 60-70
normal range aPTT: 30-40
Both PTT and aPTT are used to help regulate heparin dosages.
Therapeutic range is 1.5 to 2.5 times normal or control
What are the 7 Rights of medication administration?Right drug
right dose
Right route
Right time
Right patient
Right documentation
Right to refuse
When should you draw a peak level?30-60 minutes after medication administration
When should you draw a trough level?30-60 minutes before medication administration
When introducing foods to infants what should you teach the new parents?Introduce one food at a time to help identify allergies.
Progression of food should be “AS TOLERATED”
The nursing assessment guides decisions about progression.
What is civil law concerned with?Protection of the patients private rights
What does criminal law deal with?Rights of individuals and society as defined by legislative laws
What is nursing negligenceNegligence is malpractice that is NOT intentional. It is the failure to exercise the proper degree of care required by the circumstances that a reasonably prudent person would exercise under the circumstances to avoid harming others. It is a careless act of omission or commission that results in injury to another.
What is nursing malpractice?Malpractice is not always negligence. It is often referred to as professional negligence, it is a type of negligence. It is the failure to use that degree of care that a reasonable nurse would use under the same or similar circumstances. Malpractice is found when:
– The nurse owed a duty to the patient
– The nurse did NOT carry out the duty/breached that duty
– The patient was at a high risk of injury
– The nurse’s failure to carry out that duty caused the patients injury
Where do Standards of Care originate?Nurses are required to follow standards of care, which originate in the Nurse Practice Acts, state and federal laws, accreditation recommendations, the guidelines of professional organizations, and the written policies and procedures of the healthcare agency.
What are nurses responsible for related to the standards of care?Nurses are responsible for performing procedures correctly and exercising professional judgment when implementing healthcare providers prescriptions.
When can the nurse NOT follow the healthcare provider’s prescription and what must they do about it?Nurses MUST follow the healthcare provider’s prescription unless the nurse believes that it is in error; that it violates hospital policy; or that it is harmful to the patient. The nurse makes a formal report explaining the refusal. The nurse should file an incident (occurrence) report for any situation that may result in harm to the patient.
What should the nurse do related to advanced medical directives (ADs)Assess the patients knowledge of advance directives.
Integrate them into the patients plan of care
Provide the patient with information about advanced directives or review ADs on admission.
Have the knowledge that ADs can limit life-prolonging measures when there is little or no chance of recovery
What is documented in a living will?A person documents his or her wishes regarding future care in the event of terminal illness
What is a durable power of attorney for healthcare?The person appoints a representative (healthcare proxy) to make healthcare decisions in a document
When can restraints be used? What must the nurse do if restraints are used?Restraints can be used only: to ensure the physcial safety of the patient or other residents, when less restrictive interventions are not successful, and must have a written order of a HCP. The nurse must follow agency policy and procedure to retrain any client, Documentation of the use of restraints and of follow-up assessments must detail the attempts to use less restrictive interventions. Liability for improper or unlawful restraint lies with the nurse and the healthcare facility. 30 min pulse checks, 2 hr ROM, one on one.
Related to mental Health, how long can an involuntary admission last?72 hours
What is HIPPA and what does it requireHealth Insurance Portability and Accountability Act of 1996 established standards for the verbal, written and electronic exchange of private health information. HIPPA created patient rights to consent to use and disclose health information, to inspect and copy one’s medical record, and to amend mistaken or incomplete information. HIPPA requires all hospitals and health agencies to have specific policies and procedures in place to ensure compliance with its standards.
What is required for informed consent to be valid?the patient giving consent must be competent and of legal age. The consent is given voluntarily. The patient giving consent understands the procedure, risks/benefits, and alternative procedures. The patient has the right to have all questions answered satisfactorily. It is the duty of the HCP performing the procedure or treatment to obtain informed consent and to answer any questions the patient might have about the procedure. The RN is witnessing the signature not providing informed consent.
what type of communication and leadership is it if the person says “do it my way”?Aggressive communication/authoritarian leader
What type of communication and leadership is it if the persons says “Whatever…as long as you like me.”Passive communication/laissez-faire leader
What type of communication and leadership is it if the person says “Lets consider the options available.”?Assertive communication/democratic leader
What are the five rights of delegation?right task
right circumstance
right person
right direction/communication
right supervision
What skills are needed for SupervisionBe able to:
– give direction/guidance
– evaluate/monitor
– following up
What is the acronym S-BAR stand for?It is a interdisciplinary communication strategy that promotes effective communication between caregivers

S = situation – State the issue or problem
B = background – provide history
A = assessment – most recent VS and current findings
R = recommendation – state what should be done
What are the 3 categories of pain medications1. non-opioids: for mild pain or in combination for moderate pain
2. Opioids: for moderate to severe pain
3. Co-analgesic or adjuvant drugs (i.e. anticonvulsants, antidepressants) for neuropathic pain
Name 4 types of Nonopioid Analgesics1. Acetaminophen: Tylenol
2. Salicylates: Aspirin, Trilisate
3. NSAIDS: ibuprofen, Indomethacin, Ketorolac, Diclofenac
4. COX-2 inhibitors: Celebrex
What type of drug is Aspirin?Non opioid Analgesic

Choline magnesium trisaliclate (Trilisate) is another type of non opioid Analgesic salicylates
Acetaminophen (Tylenol) is what type of drug?
What is the maximum recommended dosage?
What should you monitor?
Nonopioid Analgesics.
Max dose: 4000 mg (4 g) in 24 hrs
Monitor liver function
What have NSAIDs (except aspirin) been linked to and what type of patient should not take NSAIDs?NSAIDs (except aspirin) have been linked to a higher risk for increased cardiovascular events, such as myocardial infarction, stroke, and heart failure. Patients who have just had heart surgery should not take NSAIDs. NSAIDs are very hard on the stomach. NO NSAIDs for Cardiac patient.
At what pain level should an Opioid Analgesic be considered?Pain level of 6 or greater. Opioids are used for moderate to severe pain.
DO NOT delegate what you can EATE = evaluate
A = assess
T = teach
What are some examples of Non-opioid Analgesic pain medicationsAcetaminophen (Tylenol)

– Aspirin
– Choline magnesium trisalcylate (Trilisate)

– Ibuprofen
– Indomethacin
– Ketorolac
– Diclofenac K
Cyclooxygenase-2 (COX-2) inhibitors
– Celecoxib
What are some types of Analgesics (used for moderate to severe pain)?Mu agonists
– Morphine
– Hydromorphone
– Methadone
– Levorphanol
– Fentanyl
– Oxycodone
– Codeine (Tylenol No.3)

Mixed agonist-antagonists
– Pentazocine

Partial agonists
– Nuprenorphine
-Buprenorphine plus naloxone

Adjuvant drugs
– used for neuropathic pain
– Antiepileptic drugs, antidepressants, and anesthetics are prescribed alone or in combination with opioids for neuropathic pain,
– Corticosteroids
What is a Mu agonist?The so-called agonist-antagonist drugs have a relationship to the opioid receptors that includes activation and blockade. Some of these drugs activate one type of opioid receptor, known as the kappa receptor, while blocking another, the mu receptor
When an opioid is prescribed in combination with a nonopioid analgesic, such as acetaminophen or a NSAID, what should you monitor?The daily dose
Name 5 non-invasive non-pharmacological pain relief techniques (1st choice of pain relief)Ten’s
heat and cold application
message therapy
relaxation techniques
guided imagery
biofeedback techniques
Name 3 Invasive non-pharmacological pain relief techniques.Nerve blocks
Interruption of neural pathways
What can cause fluid volume excess?CHF (most common)
Renal failure
What are the symptoms of fluid volume excess?Peripheral edema
periorbital edema
elevated BP
What may be some Lab findings r/t fld volume excessEverything will be decreased
Decreased: BUN, Hgb/Hct, serum osmolality, urine specific gravity and electrolytes
ConditionTreatmentCausesSymptomsLab FindingsImportant Notes
Fluid Volume ExcessGive Diuretics (Lasix), fluid restrictions, weigh daily, monitor K+
Fluid Volume DeficitStrict I&O, Replace with isotonic fluids, monitor BP, weigh dailyInadequate fluid intake, Hemorrhage, Vomiting or diarrhea, Massive edemaWeight loss, Oliguria (not enough urine), Postural hypotensionIncreased BUN, Increased or normal creatinine, Increased H/H, Increased urine specific gravity
Intracellular Electrolyte BalancePotassium K+ maintains osmotic pressure and if K+ is not in balance it may be life-threatening.
Extracellular Electrolyte BalanceSodium Na+ maintains most abundant osmotic pressure. When either the ECF or the ICF changes in concentration, fluid shifts from the area of lesser concentration to the area of greater concentration.
HyponatremiaCheck blood pressure often, restrict fluids, and be cautious with IV fluid replacement.Neuro/confusion and muscle crampsHyponatremia is a sodium (Na+) level less than 135 mEq/L.
HypernatremiaDo Not Use IVs that contain sodium, Restrict sodium diet, Weigh dailyPulmonary edema, Neuro: seizures, thirst, feverNa+ greater than 145 mEq/L
HypokalemiaGive IV potassium supplements with a max flow rate of 20 meq/hr, Encourage foods high in K+ (bananas, oranges, spinach, potatoes, milk, strawberries, apricots)Affects the cardiac system: The patient may exhibit a rapid, thready pulse, flat T waves, fatigue, anorexia, and muscle crampsHypokalemia is a K+ level less than 3.5 mEq/L

What is Hyperkalemia, what might you see with the patient and how do you treat it?

Hyperkalemia is a K+ level greater than 5 mEq/L
You may see tall, tented T waves, bradycardia, muscle weakness.
Treatment may include:
– 10%-20% glucose with regular insulin
– Kayexalate
– renal dialysis may be required

What is hypocalcemia, and what might the patient exhibit? How will you treat it?

Hypocalcemia is a Ca2+ level of less than 8.5 meq/L. It affects the muscles: You may see a + Trousseau’s sign, + Chvostek’s sign, diarrhea, numbness, and convulsions. Treatment may include: calcium supplements and vitamin D to absorb. If giving IV calcium, give it slowly. Teach patient to increase dietary calcium.

How do you test for the Chvostek sign and what happens if there is a positive response?Elicitation: Tapping on the face at a point just anterior
to the ear and just below the zygomatic bone

Postitive response: Twitching of the ipsilateral facial
muscles, suggestive of neuromuscular excitability
caused by hypocalcemia
How do you test for the Trousseau’s sign and what happens if there is a positive response?Elicitation: Inflating a sphygmomanometer cuff above
systolic blood pressure for several minutes

Positive response: Muscular contraction including flexion of the wrist and metacarpophalangeal joints,
hyperextension of the fingers, and flexion of the thumb
on the palm, suggestive of neuromuscular excitability
caused by hypocalcemia
What is Hypercalcemia? What signs and symptoms may be present? and how do you treat it?Hypercalcemia is a calcium level above 10.5 mEq/L
Calcium affects the muscles, you may see muscle weakness, constipation, n/v, dysrhythmias, and behavioral changes.

Limit vitamin D intake but push fluids. Avoid calcium-based antacids.

Administer calcitonin to reduce calcium
Renal dialysis may be required
Name 3 types of IV fluidsIsotonic: 0.9% NS, LR, and D5w
Hypotonic: 0.5% NS, 0.45% NS
Hypertonic: d5 0.45% NS, D5LR, D5NS
What is in a LR IV fluidNS + electrolytes
When should you use NS IV fluidsUse NS when you are trying to replace volume (plasma)
What are the 5 stages of griefDenial, anger, bargaining, depression, and acceptance
What should you remember when someone is dealing with death and grief– Encourage expression of anger
– Do not take away the defense mechanism or coping mechanism the person uses in a crisis.
– Customs surrounding death and dying vary among cultures. Make every attempt to understand and accommodate the family’s cultural traditions when caring for a dying patient.
What are nosocomial infectionsInfections acquired as a result of exposure to a microorganism in the hospital setting
What routes of transmission are related to HIV exposure– unprotected sexual contact (most common)
– exposure to blood through drug using equipment
– perinatal transmission – most common for children
– can occur during pregnancy, at the time of delivery, or after birth through breast feeding
Nursing assessment r/t HIV-Positive result on enzyme-linked immunosorbed assay (ELISA)
-Polymerase chain reaction (PCR) – used with neonate
– OraQuick In-Home HIV Test: positive result is only preliminary; it must be confirmed by a healthcare professional.

*Ongoing assessment, interaction with the client, and client education and support are required.**

– NCLEX testing – never choose abstinence, choose educate!
What should you know about HIV symptoms– 1 to 3 weeks; flu like symptoms
– 8-10 years for diagnosis

May begin with flu like symptoms in the earliest stage and advance to..
– severe weight loss
– secondary infections
– cancer
-neurological disease
HIV Nursing and Collaborative Management includes…– Monitor disease progression and immune function
– Initiate and monitor (ART) antiretroviral therapy: to decrease viral load and increase T cell count
– prevent development of opportunistic diseases
– detect and treat opportunistic diseases
– manage symptoms
– prevent or decrease complications of treatment
– prevent transmission of HIV
What are the goals of HIV drug therapy?– Reduce the viral load
– maintain or raise the CD4+ T cell counts. T cell counts =
Normal 800-1200 HIV 500 AIDS below 200
– Delay the development of HIV related symptoms and opportunistic diseases
What are some HIV MedicationsNucleoside reverse transcriptase inhibitors (NRTIs)
– zidovudine (AZT, ZDV, Retrovir)
– lamivudine
– abacavir
– emtricitabine
Nucleotide reverse transcriptase inhibitor (NtRTI)
Tenofovir DF (Viread)
What is the antidote for heparin toxictyprotamine sulfate
What is the antidote for coumadin toxictyvitamin K
What is afterload?the resistance that blood has to overcome when leaving the heart
What type of drug will affect afterloadCalcium channel blockers
If PVC’s are left untreated what can it lead to?Ventricular fibrillation
What is the antidote for too much ammonia?Lactulose
What is the antidote for digoxin?Digibind
What is the drug of choice for alcohol withdrawal?Librium
What is the drug of choice to treat pain in patients who are narcotic addicts?Methadone is an opioid analgesic used to detoxify and treat pain in narcotic addicts.
Why should we be concerned about the patient receiving potassium and digoxin?Potassium potentiates dig toxicity.
What does heparin prevent?Platelet aggregation
What is the medication of choice for V tach?Lidocaine
What is the medication of choice for SVT?Adenosine or Adenocard
What is the medication of choice for Asystole?Atropine
How often is nitroglycerine administered and when should you not give it?Up to 3 times (every 5 minutes); do not give when BP is less than 90/60.
What does preload affect?The amount of blood that goes to the R ventricle
Aldosterone attracts what?Sodium
Angiotensin II in the lungs is a potent?Vasodilator
How do you convert Fahrenheit to Centigrade?F+40, multiply 5/9 and subtract 40
How do you convert Centigrade to Fahrenheit?C+40, multiply 9/5 and subtract 40
EPI is always given in what type of syringe?TB syringe
What should be avoided when a patient is neutropenic?No live vaccines, no fresh fruit, no flowers
What happens when a patient has prednisone toxicity?Cushing’s syndrome, buffalo hump, moon face, high glucose, hypertension
What is the medication of choice for CHF?Ace inhibitors
What is the medication used for anaphylactic shock?Epinephrine
What is the medication of choice for Status Epilepticus?Valium
What is the medication of choice for a bipolar person?Lithium
What does a low residue diet mean?Low fiber
Where is insulin produced?Beta cells of pancreas
What drug is contraindicated in Pancreatitis? What pain medication should be used?Do not give Morphine for pancreatitis because it causes spasms of the Sphincter of Oddi, give Demerol instead.
Never IV push what electrolyte?K+
What is a sign of a fat embolism and what medication would you give?Petechiae is a sign of a fat embolism. Treat with heparin.
Too much CO2 causes what?Vasoconstriction
Communicating with Chinese AmericansMost Chinese Americans prefer formal distance as a form of respect and may be uncomfortable with direct eye contact and face-to-face communications. Turning away during a conversation is not a sign of disinterest. Avoid walking around them to face them directly during conversations, as it may be perceived as rude. Highlighting the importance of instructions for healthcare maintenance should be approached with sensitivity to avoid being viewed as degrading.
Low Risk TherapiesLow-risk therapies include non-invasive and non-pharmacological options such as meditation, relaxation techniques, imagery, music therapy, massage, touch, laughter, humor, and spiritual practices like prayer. These therapies are considered low risk when performed by nurses trained and experienced in their use.
High Risk for Obesity and Diabetes MellitusNative Americans, Latino Americans, Hispanic Americans, and African Americans are at higher risk for obesity and diabetes mellitus due to their health and dietary practices. Asian Americans have a lower risk for these conditions.
Fluid Volume Excess: HypervolemiaHypervolemia is a condition characterized by an excessive amount of fluid in the vascular space, including veins, arteries, capillaries, and heart chambers.
Causes of Fluid Volume Excess: HypervolemiaCauses include heart failure (leading to decreased cardiac output and urinary output), renal failure, and medications high in sodium (e.g., alka-seltzer, fleet enemas, IV fluids with sodium) that promote water retention in the vascular space.
Hormonal Regulations of Fluid VolumeAldosterone (from adrenal glands) increases sodium and water retention to raise blood volume. Atrial Natriuretic Peptide (ANP, from the heart’s atria) promotes the excretion of sodium and water.
Diseases Related to AldosteroneToo much aldosterone can lead to conditions such as Cushing’s syndrome and Hyperaldosteronism (Conn’s syndrome). Insufficient aldosterone is associated with Addison’s disease, which leads to decreased fluid volume.
Atrial Natriuretic Peptide (ANP) FunctionANP works oppositely to aldosterone, causing the excretion of sodium and water to regulate fluid balance.

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