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2024-2025 NCLEX Rationals and Study Guide with Answers (168 Solved Questions)

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    N clex rationals and study guide 100% VERIFIED CORRECT ANSW ERS 2024/2025 right occiput posterior position will have back pains with labor "back labor" positioning woman and hands and knees will relive some of the pressure and help facilitate rotation into an anterior position. Right occiput anterior optimal for birth Predisposing factors for delirium are? adva nced age neurodegenerative disease (stroke, dementia) polypharmacy infection ABG imabalance Surgery untreated pain occipital transverse when fetus remains in OP or OT position labor is prolonged. fetus will usually reposition to OA. manual rotation may be required if this position persist. Agoraphobia

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    fear or anxiety about being in certain situations or any physical spaces. they are highly concerned about having trouble escaping or being able to get help in the event of a panic attack. Hypertensive medicati ons Contraindicated in Pregnancy that can have tetragenic affects are? ACE inhibitors and ARB's Acceptable abbreviation for documentation c/o ac pc QID cm Unacceptable abbreviations for documentation q1d qd qod SSRI u Must have a zero before decimal 0.05 N o trailing zeros after decimal 1.000 Major complications of oligohydramnios are; Pulmonary hypoplasia Umbilical cord compression *** additional staff will be needed during delivery in case of CPR

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    Major complications of TNF inhibitor(inhibits inflammatory response) drugs are; type of drugs? infections bone marrow suppression type of drugs include; infliximab, entanercept, side effects of furosemide in pt's chronic kidney disease would be ? ototoxicity what are the s/s of abstinence syndrome ? ANS: stuffy nose, sweating, stuffy nose, sneezing, tachycardia, tachypnea CNS: irritability, high pitched crying, restless, abnormal sleep pattern, hypertonicity GI: poor feeding, vomiting, diarrhea, what are the 4 s/s of nephrotic syndrome? massive proteinuria hypoal buminemia edema hyperlipidemia what instruction do you give your patient prior to their colonoscopy procedure? Clear liquid diet the day before NPO 8 - 12 hours before exam take bowel cleansing agent day before (GoLYTELY) uterine fundus location during prenatal exam after 20 weeks gestation the fundus location = gestational age.

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    intussesception is when one part of the intestine prolapses and then telescopes into another part of the intestine. It is also the most frequent ca use of bowel obstruction during infancy. what are the signs and symptoms to look out for. intermitten pain with legs drawn up. severe progressive pain with inconolable crying. ongoing obstruction leads to mucosal ischemia, and current jelly stools (mucus and bleeding mixed) pregnant women have a blood volume that increases between 40 - 45% to meet increased O2 demands and nutritional demands for the fast growing fetus. what is the normal hemoglobin, hematocrit, WBC, RBC and platelet count ? what are the sign s of uterine rupture? abnormal FHR patter constant abdominal pain loss of fetal station sudden cessation of uterine contraction severe signs are hemorrhage, hypovolemic shock and maternal tachycardia Polycythemia Vera is a chronic myloproliferation disord er in which the bone marrow produces abnormal high amounts of RBC's. What is the danger with this disease and what is the treatment for it? the danger with this disease is blood clotting r/t increase viscosity of the blood tx: periodic phlebotomy to remov e 300 - 500 millimeters of blood until hematocrit and hemoglobin levels are meet. what are the common causes of bilateral neuropathy?

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    Diabetic neuropathy *** most common alcohol auto immune ( Guillian Barre syndrome) **always establish if the neuropathy pai n was present before surgery to rule out if this is a surgical complication lymph nodes are not normally palpable in adults... however what type of palpable node would be considered a normal finding and why? lmyph nodes that are 05. - 1 cm in size, firm, mob ile and non - tender - this could be r/t some type of trauma ie. masectomy what is NOT considered a normal finding when palpating a lymph node? firm, hard, fixed nodes - r/t malignancy tender node - r/t inflammation Purpura: a reddish - purple blotch on the sk in that do not blanch with pressure due to bleeding underneath the skin. this finding is significant and requires further assessment. S/S of hypoglycemia are? shakiness/trembling, palpitations, anxiety/arousal, restlessness, diaphoresis and pallor. - durin g hypoglycemia the body relates epinephrine ... in addition the brain is deprived of glucose therefore LOC is altered with possible seizures, confusion, coma. what are the standard heparin doses when flushing CVC lines? 2 - 3 mL containing 10 units/mL - 100 units/mL what is the normal CVP?

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    if CVP is Low or High what does that indicate? Proximal port lumen is used to measure CVP since it is located in the right atrium 2 - 6 mm Hg normal CVP Low CVP = hypovolemia High CVP= right ventricular failure of fluid vo lume overload Leoapolds maneuver used to detect fetal presentation by palpating the abdomen McRoberts maneuver sharply pressing the thigh into the abdomen to straighten out the sacrum. used for shoulder dystocia abciximab eptifibatide tirofiban what type of drugs are these and why are they used? what are the common side effects? contraindications? nursing interventions? Glycoprotein (GB) IIb/IIIa receptor inhibitors platelet inhibitors and are used to prevent occlusion of treated coronary arter y procedures. they are also used to prevent ischemia. common side effects are bleeding and thrombocytopenia contraindicated with traumatic procedures, IV lines and IM injections

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    Monitor: blood counts (hemoglobin and platelet), heart rate and rhythm and sings of bleeding. what do you do once the waveform on a Pulmonary artery catheter has been "wedged" ? once the waveform is "wedged" the ballot can be inflated. Do not inflate for more than 10 - 15 seconds to avoid damage. lock the ballon port. What medicati ons should be avoided in patients with chronic kidney disease? NSAID's = nephrotoxic alendronate (Fosamax) risedronate (Actonel) ibandronate (Boniva) what are the classifications of these medications? SE? Biophosphonates MOA: decrease bone resorption to minimize the loss of bone density. Teaching: take this med with a full glass of water and remain in an upright position for at least 30 min. what are the clinical manifestations of bacterial meningitis for infants <2 yrs fever or hypothermia irritability, frequent seizures high pitched cry poor feeding and vomiting nuchal rigidity possible bulging fontenells

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    what is the most common acute complications of bacterial meningitis? hydrocephalus - fluid in brain -- > brain damage. long term complications include hearing loss, brain damage, learning disabilities. what are the immunization for a 6 month old child? use the mnemonic (Be DR HIP) Hep B Dtap RV(rotovirus) Hib (hamephilus influenza) IPV (inactivated polio virus) PVC (pneumococcal conjugate virus) how oft en should IV catheters be removed or replaced? Q 76 - 96 hrs unless complications occur then remove sooner. explain the steps to a low pressure huff cough for patients with COPD 1. position upright 2. inhale through nose, then prolonged exhale through purse d lips for 3 breaths 3. hold breath for 2 to 3 seconds while keeping throat open 4. deeply inhale, lean forward then force out breath making a "ha!" sound: repeat 2X 5. breath in deeply and give the last forced "ha!" cough nursing measures after tonsillect omy ; 1. apply ice on neck 2. analgesics (rectal/IV) 3. Place on abdomen or side lying position nursing teaching to parents after tonsillectomy;

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    1. a low grade fever is expected 2. child may report ear pain 5 - 10 days post op 3. chewing gum can reduce muscle spasms 4. observe for s/s of hemorrhage : irritable, constant swallowing, throat clearing *** contact HCP stat 5. pt should not participate in strenuous activity up to 14 days post op r/t increase risk for hemorrhage! 6.. t hroat might be white with foul odor for the first 5 - 10 days post op... this is an expected finding. interventions to manage lymphedema include; - massage are to help mobilize fluid - use intermittent compression sleeve - elevate arm above heart - isometric exe rcise - avoid IV on affected side low T4, and low T3 while TSH compensates and is elevated is indicative of what disorder? what are the s/s of this disorder? Hypothyroidism SS: weight gain, confusion, hair loss, forgetfulness and cold intolerance, bradyca rdia, joint and muscle aches. what are some non - modifiable breast cancer risk factors? What are some modifiable breast cancer risk factors? non - modifiable: - hx of 1st degree relative with breast cancer

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    - BRACA genetic mutation - hx of endometrial canver - menarche before age 12 and menopause after age 55 modifiable: - hormone therapy - dietary fat intake - smoking, alcohol - postmenopausal weight gain - sedentary lifestyle what of the signs when nearing death? mottling of the extremities (coolness/paleness) relaxed jaw (open mouth) difficulty maintaining body posture eyelids half open chyenne stokes (uneven respirations with apnea) clinical manifestations of asthma aspiration include; accessory muscle use chest tightness diminished breath sounds high pitched wheezing on expiration tachypnea cough and hyper sections of mucus splenic sequestration crisis when a large # of sickle cells get trapped in the spleen -- > splenomegaly ***this is an emergency that can lead to hypovolemic and hypotensive shock

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    Nursing interventions to reduce the risk for aspiration for pt. with ENT feeding include; 1. assess GI intolerance to tube feeding in regular intervals q4h (abd distention, 2. assess tube placement 3. keep hob >or equa l to 30 degrees 4. keep endotracheal cuff inflated 5. suction any secretions 6. use caution with sedatives 7. avoid bolus tube feeding hirshburg's disease clinical manifestations of disease? and the fatal complications? what is the tx? occurs when a child is born with some sections of the distal large intestine missing nerve cells -- > the anal splinter unable to relax. onset manifestations include; not able to pass meconium within the expected 24 - 48 hrs. difficulty feeding, vomit of green bile. fatal compl ications include; enterocolitis, sepsis, death. enterocolitis -- > fever, lethargy, explosive foul smelling diarrhea, rapidly worsening abdominal distention. tx: surgical removal of the affected area. reducing the risk for Diverticular episodes include the following; since the etiology of this disease has been linked to chronic constipation - preventing constipation would reduce the risk for diverticula forming and becoming inflamed. constipation prevention include, drinking lots of water, exercise, and incr ease in fibers foods/supplements. Risk factors for cervical cancer inlude? - HPV infection - hx of STD's

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    - early onset of sexual activity - multiple or high risk sexual partners - immunosuppression - low socioeconomic status - tobacco use causes for respiratory alkalosis fever hyperventilation hypoxia hysteria over ventilation by ventilators pain *** if the pt. condition causes overstimulation of the respiratory system monitory pt. for respiratory alkalosis. causes for respiratory acidosis asthma atelectasis bra in trauma bronchitis CNS depressants emphysema hypoventilation pulmonary infections, edema, emboli *** if the pt. conditions causes an obstruction of the airway or depresses the respiratory system monitor pt for respiratory acidosis. causes for metabolic acidosis

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