NCLEX/HESI Review

Janine Messer BSN, RN

POW
Key Words
Elimination
Maslow
Erickson
ADPIE
ABC

Test taking strategies

 Do not fall into the trap of predicting answers
on the NCLEX-PN. There is a temptation to
select what you believe is the correct answer
when you see it jump out at you from the
answer choices.
Dont do it!
Make sure to carefully consider each answer
choice
 When doing a physical assessment of a 17-
year old primigravida who is at 30 weeks of
gestation, a nurse should expect which
finding is related to mild preeclampsia?

1. Epigastric discomfort
2. Trace proteinuria
3. Dyspnea
4. Blood pressure of 150/100 mm hg
 See it jump out from choice 4?
This is the wrong answer
Instead work your way through each choice
and make eliminations
After you read your choices carefully, you
will see all findings are related to
preeclampsia
How do you choose?
The question is asking about mild
preeclampsia so choices 1,3, and 4 would
be out because these are symptoms of
severe preeclampsia
Only choice 2 is related to mild
preeclampsia
 You need to choose the best answer from
the four you are given.
This is where your practice of eliminating
answer choices will really pay off

What if every answer choice is

correct?
 If you see the words:most, first, best,
initial in a question, this means you must
establish priorities
You are picking the answer with the
highest priority

Prioritization
 A nurse responds to the cardiac monitor
alarm of a patient and observes that the
patient has atrial flutter. The patient is
sitting up in bed and is responsive. Which of
the following actions should the nurse take
first?

1. Institute carotid sinus massage

2. Assess the patient for dyspnea
3. Initiate cardiopulmonary resuscitation for
this patient
4. Place the patient in the Trendelenburg
position
Assess the patient for dyspnea

Utilize PHAN
Priority-Hierarchy-ABCs-Nursing
process(adpie)
 Always assess before you act
When you see a question regarding care that
includes both assessments and
implementations in the answer choices, ask
yourself, Is there enough information given
to take action?
If there is not, you must assess first
In the previous question, three of the answer
choices were implementations and only one
answer (choice 2) involved assessment

The Nursing Process

 The night after an exploratory laparotomy, a
patient who has a nasogastric tube attached
to low suction reports nausea. A nurse
should take which of the following actions
first?

1. Administer the prescribed antiemetic to the

patient
2. Determine the patency of the patients
nasogastric tube
3. Instruct the patient to take deep breaths
4. Assess the patient for pain
Determine the patency of the patients
nasogastric tube

You can scan the choices immediately and

see that two of the choices require you to
take action and are therefore
implementations (1 and 3) Choice 4 is
tempting because you see the word
assess but think further, is pain an issue
for this patient? No.nausea is.
 When faced with both assessments and
implementations, eliminate the
implementations first unless you are
certain the question gives you enough
information to take action
If the question does give you enough
information to act, eliminate the answer
choices involving unnecessary assessment

Assess first and then Implement

 A nurse enters a client's room and finds that
the wastebasket is on fire. The nurse
immediately assists the client out of the
room. The next nursing action would be to:

1. Call for help.

2. Extinguish the fire.
3. Activate the fire alarm.
4. Confine the fire by closing the room door.
 Activate the fire alarm

The order of priority in the event of a fire is

to rescue the clients who are in immediate
danger.
The next step is to activate the fire alarm.
The fire is then confined by closing all
doors.
Finally, the fire is extinguished.
 A nurse enters the nursing lounge and
discovers that a chair is on fire. The nurse
activates the alarm, closes the lounge door,
and obtains the fire extinguisher to
extinguish the fire. The nurse pulls the pin
on the fire extinguisher. The next action
would be to:

1. Aim at the base of the fire.

2. Squeeze the handle on the extinguisher.
3. Sweep the fire from side to side with the
extinguisher.
4. Sweep the fire from top to bottom with the
extinguisher.
Aim at the base of the fire

A fire can be extinguished by using a fire

extinguisher.
To use the extinguisher, the pin is pulled
first.
The extinguisher should then be aimed at
the base of the fire.
The handle of the extinguisher is squeezed,
and the fire is extinguished by sweeping
from side to side to coat the area evenly.
 A nurse is caring for a client who has hand
restraints. The nurse assesses the skin
integrity of the restrained hands:

1. Every 2 hours
2. Every 3 hours
3. Every 4 hours
4. Every 30 minutes
Every 30 minutes

The nurse needs to assess restraints and

skin integrity every 30 minutes. Therefore
options 1, 2, and 3 are incorrect.
Agency guidelines regarding the use of
restraints should always be followed.
 A nurse is assisting with planning care for a
client with an internal radiation implant. Which
of the following should be included in the plan
of care? Select all that apply.

1. Wearing gloves when emptying the client's

bedpan
2. Keeping all linens in the room until the implant
is removed
3. Wearing a film (dosimeter) badge when in the
client's room
4. Wearing a lead apron when providing direct
care to the client
5. Placing the client in a semiprivate room at the
end of the hallway
Wearing gloves when emptying the client's bedpan

Keeping all linens in the room until the implant is

removed

Wearing a film (dosimeter) badge when in the

client's room

Wearing a lead apron when providing direct care

to the client

A private room with a private bath is essential if a client

has an internal radiation implant.
This is necessary to prevent the accidental exposure of
other clients to radiation.
The remaining options identify interventions that are
necessary for a client with a radiation device.
 A community health nurse is conducting a
teaching session about terrorism with
members of the community and discussing
information regarding anthrax. The nurse
tells those attending that anthrax can be
transmitted via which route(s)? Select all
that apply.

1. Skin
2. Kissing
3. Inhalation
4. Gastrointestinal
5. Direct contact with an infected individual
6. Sexual contact with an infected individual
Skin

Inhalation

Gastrointestinal

Anthrax is caused by Bacillus anthracis, and

it can be contracted through the digestive
system, abrasions in the skin, or inhalation.
It cannot be spread from person to person.
 right patient
right drug
right dose
right route
right time

5 Rights of Medication
Administration
 Does the order contain all necessary
information? (5 rights of medication
administration)
Is the dose within the recommended range?
Is the dose safe?
Does the order contain all necessary
information? (5 rights of medication
administration)
The most common error in medication calculation
questions on the NCLEX is related to conversion
(ie. Liters to milliliters)
Remember to use the correct rules for rounding
numbers

Basic Rules for Dosage

Calculations
The medication prescribed is
hydromorphone hydrochloride (Dilaudid), 3
mg intramuscular every 4 hours as needed.
The medication label reads hydromorphone
hydrochloride (Dilaudid), 4 mg/1 mL. The
nurse prepares to administer how many mL
to the client?
0.75 mL

3mg__ x 1ml= 0.75 mL

4mg
The medication prescribed is digoxin
(Lanoxin), 0.25 mg orally daily. The
medication label reads digoxin (Lanoxin),
0.125 mg/tablet. The nurse prepares how
many tablet(s) to administer the dose?
2 tablets

0.25 mg = 2 tablets
0.125 mg
The medication prescribed is atropine
sulfate, 0.4 mg intramuscularly,
immediately. The medication label states
atropine sulfate, 0.3 mg/0.5 mL. The nurse
prepares how much medication to
administer the dose? Round to the
nearest tenth position.
0.7 mL

0.4 mg x0.5 mL = 0.66 mL= 0.7 mL

0.3 mg
 A nursing instructor asks a nursing student
to describe the procedure for relieving an
airway obstruction on an unconscious
pregnant woman at 8 months' gestation.
The student describes the procedure
correctly if the student states to:

1. Place the hands in the pelvis to perform

the thrusts.
2. Perform abdominal thrusts until the object
is dislodged.
3. Perform left lateral abdominal thrusts until
the object is dislodged.
4. Begin cardiopulmonary resuscitation (CPR)
Begin cardiopulmonary resuscitation (CPR)

If there's a visible blockage at the back of the

throat or high in the throat, reach a finger into
the mouth and sweep out the cause of the
blockage.
Be careful not to push the food or object deeper
into the airway. If the object remains lodged and
the person doesn't respond after you take the
above measures initiate CPR.
The chest compressions used in CPR may
dislodge the object. Remember to recheck the
mouth periodically.
Options 1, 2, and 3 are incorrect and can cause
harm to the woman and the fetus.
 A nurse on the day shift walks into a client's
room and finds the client unresponsive. The
client is not breathing and does not have a
pulse, and the nurse immediately calls out
for help. The next nursing action is which of
the following?

1. Deliver breaths.
2. Give the client oxygen.
3. Start chest compressions.
4. Ventilate with a mouth-to-mask device.
Start chest compressions.

The nurse would follow C-A-B,

compressions, airway, and breathing.
Therefore the next nursing action would be
to start chest compressions.
 A nurse witnesses a neighbor's husband
sustain a fall from the roof of his house. The
nurse rushes to the victim and determines
the need to open the airway. The nurse
opens the airway in this victim with the use
of which method?

1. Flexed position
2. Head tiltchin lift
3. Jaw thrust maneuver
4. Modified head tiltchin lift
Jaw thrust manuever

Prior to initiating cpr, remember to assess

scene safety first.
If a neck injury is suspected, the jaw thrust
maneuver is used to open the airway.
The head tiltchin lift produces
hyperextension of the neck and could cause
complications if a neck injury is present.
A flexed position is an inappropriate position
for opening the airway.
 A nurse is developing a plan of care for a
client who is scheduled for surgery. The
nurse would include which of the following
activities in the nursing care plan for the
client on the day of surgery?

1. Have the client void immediately before

surgery.
2. Avoid oral hygiene and rinsing with
mouthwash.
3. Verify that the client has not eaten for the
last 24 hours.
4. Report immediately any slight increase in
blood pressure or pulse.
Have the client void immediately before
surgery

The nurse would assist the client with voiding

immediately before surgery so that the bladder
will be empty.
Oral hygiene is allowed, but the client should not
swallow any water.
The client usually has a restriction of food and
fluids for 8 hours before surgery rather than 24
hours.
A slight increase in blood pressure and pulse is
common during the preoperative period; this is
generally the result of anxiety.
 A nurse is caring for a client who is
scheduled for surgery. The client is
concerned about the surgical procedure. To
alleviate the client's fears and
misconceptions about surgery, the nurse
should:

1. Tell the client that preoperative fear is

normal.
2. Explain all nursing care and possible
discomfort that may result.
3. Ask the client to discuss information
known about the planned surgery.
4. Provide explanations about the procedures
involved in the planned surgery.
Ask the client to discuss information
about the planned surgery

Explanations should begin with the

information that the client knows.
Option 1 is a block to communication, and
options 2 and 4 may produce additional
anxiety in the client.
 A nurse is collecting data from a client who is
scheduled for surgery in 1 week in the
ambulatory care surgical center. The nurse
notes that the client has a history of arthritis
and has been taking acetylsalicylic acid
(aspirin). The nurse reports the information to
the surgeon and anticipates that the surgeon
will prescribe which of the following?

1. Discontinue the aspirin immediately.

2. Continue to take the aspirin as prescribed.
3. Discontinue the aspirin 48 hours before the
scheduled surgery.
4. Decrease the dose of the aspirin to half of
what is normally taken.
Discontinue the aspirin 48 hours before
the scheduled surgery

Antiplatelets alter normal clotting factors

and increase the risk of hemorrhage.
Aspirin has properties that can alter the
clotting mechanism and should thus be
discontinued at least 48 hours before
surgery.
 A nurse obtains the vital signs on a
postoperative client who just returned to
the nursing unit. The client's blood pressure
(BP) is 100/60 mm Hg, the pulse is 90
beats per minute, and the respiration rate is
20 breaths per minute. On the basis of
these findings, which of the following
nursing actions should be performed?

1. Shake the client gently to arouse.

2. Continue to monitor the vital signs.
3. Call the registered nurse immediately.
4. Cover the client with a warm blanket.
Continue to monitor the vital signs

A slightly lower-than-normal BP and an

increased pulse rate are common after surgery.
The level of consciousness can be determined
by checking the client's response to light touch
and verbal stimuli rather than by shaking the
client.
Warm blankets are applied to maintain the
client's body temperature.
There is no reason to contact the registered
nurse immediately.
 A client arrives to the surgical nursing unit
after surgery. The initial nursing action is to
check the:

1. Patency of the airway

2. Dressing for bleeding
3. Tubes or drains for patency
4. Vital signs to compare with preoperative
measurements
Patency of the airway

If the airway is not patent, immediate

measures must be taken for the survival of
the client.
After checking the client's airway, the nurse
would then check the client's vital signs.
This would then be followed by checking the
dressings, tubes, and drains.
A nurse is monitoring an adult client for
postoperative complications. Which of the
following would be the most indicative of a
potential postoperative complication that
requires further observation?

1. A urinary output of 20 mL/hour

2. A temperature of 37.6 C (99.6 F)
3. A blood pressure of 100/70 mm Hg
4. Serous drainage on the surgical dressing
Urine output of 20 ml/hour

Urine output is maintained at a minimum of at

least 30 mL/hour for an adult.
An output of less than 30 mL/hour for each of
two consecutive hours should be reported to
the surgeon.
A temperature more than 37 C (100 F) or
less than 36.1 C (97 F) and a falling systolic
blood pressure less than 90 mm Hg are to be
reported.
The client's preoperative or baseline blood
pressure is used to make informed
postoperative comparisons.
Moderate or light serous drainage from the
surgical site is considered normal.
A nurse monitors the postoperative client
frequently for the presence of secretions in
the lungs, knowing that accumulated
secretions can lead to:

1. Pneumonia
2. Fluid imbalance
3. Pulmonary edema
4. Carbon dioxide retention
Pneumonia

The most common postoperative respiratory

problems are atelectasis, pneumonia, and
pulmonary emboli.
Pneumonia is the inflammation of lung tissue that
causes a productive cough, dyspnea, and crackles.
Fluid imbalance can be a deficit or excess related to
fluid loss or overload.
Pulmonary edema usually results from left-sided
heart failure, and it can be caused by medications,
fluid overload, and smoke inhalation.
Carbon dioxide retention results from the inability
to exhale carbon dioxide in clients with conditions
such as chronic obstructive pulmonary disease.
Nice Job!!