Kaplan nursing assessment test 180 questions quizlet

3/16/2021Kaplan NCLEX Readiness Exam Flashcards | QuizletKaplan NCLEX Readiness ExamTerms in this set (180)The nurse cares for a clientwith a cuffed tracheostomytube. Before performing oralcare, the nurse notes that theclient's tracheostomy cuff isinflated. Which of the followingis the MOST appropriate actionfor the nurse to take?1. Leave the cuff inflated andsuction through thetracheostomy.2. Deflate the cuff and suctionthrough the tracheostomytube.3. Inflate the cuff pressure to40 mm Hg before suctioning.4. Adjust the wall suctionpressure to 160 to 180 mm Hgbefore suctioning.1) CORRECT - Implementation: outcome desired;cuff inflation decreases the risk of aspiration; cuffposition and pressure should be assessedfrequently; swallowing and breathing will causetracheostomy tube movement2) Implementation: outcome not desired;accumulated oral secretions above the cuff willdrain into the bronchi; increased risk of infection3) Implementation: outcome not desired; cuffpressure should be less than 20 mm Hg (25 cmH2O); risk of trauma to trachea with higherpressures4) Implementation: outcome not desired; increasesthe risk of trauma to lower airways

3/16/2021Kaplan NCLEX Readiness Exam Flashcards | QuizletA young adult brings a friendto the emergency departmentand states that the friend hasbeen using heroin. Whichaction by the nurse is theMOST appropriate?

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The client tells the clinic nursethat the client is thinking aboutusing nicotine polacrilex(Nicorette). Which question isMOST important for the nurseto ask?

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3/16/2021Kaplan NCLEX Readiness Exam Flashcards | Quizlet3/139The nurse cares for the client

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Test, CORRECT Implementation

pre-test; mostly MC; answers are my GUESSES; correct ones to come!

Terms in this set (172)

2
NOTES:
Although their scope of practice can vary between states, you should assume that, in the NCLEX hospital, they are able to obtain vitals and blood glucose levels and ambulate, bathe, feed and assist with the toileting of stable patients. Of course, this is not an exhaustive list. The term stable is quite important here. Unstable patients, like those who are freshly post-op and those in the intensive care units, should be cared for more closely by the RN. Assessments are outside of the UAP's scope of practice and should never be delegated to them. UAPs can count the heart rate and respiratory rate, but they cannot decide if it is appropriate for the patient. That is your job.
Licensed practical nurses and licensed vocational nurses are able to administer medications, reinforce the teachings of the RN, provide wound care, carry out the interventions in the nursing care plan, and evaluate patients. Additionally, they can perform all the UAP's tasks. The RN must perform the initial assessment, but the LPN/LVN can perform follow-up assessments and alert the RN to changes in the patient.

The nurse prepares to change the central line dressing on a client. Arrange the steps of the procedure in the correct order from first to last. All options must be used.
1. Open supplies to create a sterile field.
2. Apply nonsterile gloves.
3. Apply an occlusive dressing.
4. Remove old dressing and wash hands.
5. Cleanse the area with antiseptic solution (e.g., swab stick with chlorhexidine) in a circular motion.
6. Apply sterile gloves.
1.1, 2, 4, 5, 6, 32.1, 4, 2, 6, 5, 33.2, 4, 1, 6, 5, 34.2, 4, 6, 1, 5, 3

A male client is admitted for evaluation of hematuria. An intravenous pyelogram (IVP) is ordered. The client asks the nurse to explain what will happen to him during the IVP. Which explanation by the nurse is most accurate?
1."An intravenous line will be inserted, dye injected into it, and then x-rays will be taken of your kidneys, ureters, and bladder."2."A scope will be inserted into your penis and up to the bladder so that the inside of your bladder can be visualized."3."An indwelling urinary catheter will be inserted, dye will be injected into it, and then x-rays will be taken of your bladder and ureters."4."A small incision is made in the kidney, dye injected into it, and then x-rays will be taken of your kidneys, ureters, and bladder."

Which sequence represents the order in which the nurse performs an assessment of a client's abdomen?
1.Inspect, auscultate, percuss, and palpate.2.Auscultate, inspect, percuss, and palpate.3.Palpate, percuss, auscultate, and inspect.4.Percuss, palpate, auscultate, and inspect.

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