Next Gen NCLEX Questions & Rationales Walkthroughs for NCLEX RN | Fundamentals made EASY

hey want to pass the enlex well let's walk through some key questions that you'll need to know and if you want a ton of questions with rationals for free simply click the link in the description below to create your free simple nursing account all right let's walk through this case study together and always remember to mentally highlight the key words that risk safety so starting at the top remember to read the intro and think safety think of three things that are going to kill or harm this client with immobility so number one skin breakdown and pressure injuries is a huge risk for safety number two is contractures or basically stiffening of the joints and number three is a risk for blood clots or even Venia stasis since the client is bedridden now step number two look at the tabs and mentally highlight key wordss that risk safety so now let's look at tab number one the diagnosis list so again we're only reviewing this the client has Type 2 diabetes left extremity paralysis as well as p a which is a huge risk for skin breakdown also decreased profusion and delayed wound healing now let's click over to tab number two we have to consult with the wound nurse also clean the dorsal glal wound with normal saline and pack it with calcium alanate dressing every single day this indicates a pressure injury is present also a culture for the dorsal gluteal wound just to check for a potential infection now step number three always find these keywords before looking at each item or each question so now that we found each key term that risk safety you can now go through each item more confidently when answering each specific question so remember don't be scared be prepared simply find each key term that risks safety before jumping into the question all right let's dive into the question the question is asking which of the following should be included and it's a select all that apply question I hate SATA questions just as much as you do and remember SATA is just one letter away from Satan okay now the problem here is signs and symptoms of infected pressure injury so for the solution before looking at the options think about signs and symptoms of an infection so we're thinking fever warmth redness or even foul smelling drainage if you see those key terms it's most likely an infection on the enlip now let's look at the options here the first option is fever well yes of course this is correct remember the temperature increases to fight the infection how about the next option foul smelling drainage yeah s infected wound debris produces odor how about option number three wound redness of course just simply look at the key terms here it's associated with irritation from infection now option four is also correct here wound that is warm to touch remember localized warmth is due to that increased blood flow to fight the infection now the tricky one was the last option edema basically that waterbed skin while the body here increases nutrients as well as fluids and wbc's to that area to destroy the infection so in this case all the options are correct and you got to watch out for that on the enlex because this could happen okay now on to the Matrix questions that was weird it's probably a glitch in The Matrix all right now for the next question the question is asking for each assessment finding click to specify if this indicates a stage one stage two stage three or stage four pressure injury and remember each each finding May support more than one stage the problem here is we have to identify the types of pressure injuries so for the solution before looking at the options and getting super confused stop and think about the different types and stages of pressure injuries as well as the signs and symptoms of each so to make this super simple simply think four layers of skin for four stages of pressure injury so in stage number one only one layer of skin is affected the epidermis so we see non-blanchable redness of skin that's intact so remember only the epidermis is affected and in stage two we have two layers of skin that is affected so remember the skin breaks we have an open wound affecting both the epidermis as well as the dermis and the skin appears red or pink on the wound bed now what do you think stage three would be well yes of course three layers of skin affected this is what's known as full thickness skin loss extending down in the sub cutaneous tissue so through the epidermis and the dermis down to the subcutaneous fatty tissue now moving on to stage four well what do you think that's going to be of course four layers affected it extends all the way down into the muscle even the bone and tendon oh this one's really serious but it's not as serious as the unstageable the full thickness skin loss with escar and even sloth all right now finally for the options let's go through the assessment findings and find if it's stage 1 2 3 or four so starting with nonblanchable aemma so simply think one layer of skin affected so it's got to be stage one the key term is non-blanchable intact red skin here now how about the next one here opening of the dermis and epidermis so again let the question help you epidermis and dermis we have two layers of skin affected so it's got to be type two now moving on to the next one extends into the subcutaneous tissue now it sounds a lot like we have three layers of skin affected so it's got to be stage3 and the last one here involves fascia muscle and even possibly bone so man that is four layers affected so it's got to be stage number four this question is asking to select three diagnosis that increases the client's risk for pressure injury development the problem here is conditions that increase the risk for pressure injury so for the solution solution before looking at the options what do you think is going to increase pressure injury risk well number one is immobility because remember bedridden clients have extended pressure even on bony prominences number two is diabetes which I call diet trees very sugary syrupy blood the blood is turned to mud from all that high sugar and this leads to poor blood flow and poor wound healing now the last one here is vascular disease so any type of vascular disease impairs circulation which impairs healing so now let's dive into the diagnosis and pick three first is hypothyroidism well this one's incorrect hypothyroidism causes dry skin and fatigue even weight gain there's no significant increase in the risk of pressure injury here what about Diabetes metis Type 2 well yes of course remember diabetes is diat trees from all that sugar in the blood so this leads to poor blood flow and delayed wound healing and increase the risk for pressure injury how about Peripheral arterial disease that pad well again let the name help you Peripheral arterial disease there's disease in the arteries here so of course we're going to see impaired circulation and decreased perfusion that impaires oxygen so this one is correct what about paralysis of the lower extremities well paralysis leads to decreased blood flow and even impaired sensation now the client with paralyzed legs may not notice pain pressure or even injury which increases their risk now the last option is incorrect because gird is just fancy words for gastric reflux or basically heartburn that indigestion but it doesn't increase the risk for pressure injury on the skin that's more of a GI thing this question is asking us to complete the following sentence by choosing from the list of options the problem here is the hcp orders related to The Infected pressure injury so for the solution before looking to the options think about safety number one is culture the wound first before giving antibiotics then we apply Wound Care number two is frequent skin assessments and the last one here is reposition frequently as well as increase fluids okay now that we brainstormed let's dive into the options here so the question's asking the nurse must first blank followed by blank but if you were to ask me the nurse must First grab some wine followed by a back massage all right but serious the nurse must first blank so let's look at response one are we going to culture the dorsal wound well yes this is priority because it determines the causing factor of the infection now the rest of the options in column one are incorrect because we're not going to administer the IV antibiotics this should only be done after the culture is performed and we're not going to consult with the wound Cur ners because this is not the priority or that first initial action it should always be to culture the wound so now that we know that we must first culture that wound what are we going to follow up doing well the correct answer here in option two is administer the IV antibiotic this directly addresses the wound infection and the rest of the options are incorrect and let me explain why inserting an indwelling urethal catheter fancy words for a fley this action does not address the infected pressure injury and the last option is incorrect because simply administering zinc 20 mg my mouth is not the thing to do we're simply giving the client a vitamin and the client needs needs antibiotics this question is asking us to click to specify the nursing action that is appropriate for the client each category May support more than one potential action the problem here is writing a plan of care for stage three dorsal glal pressure injury so for the solution before looking at the options think about interventions for a dorsal glal pressure injury so number one we have to assess the skin and document it number two is always culture the wound first then give out of Val s and then follow up with wound care also we got to be thinking about frequent position changes and even hygiene care and then very lastly is nutrition increase those fluids and increase protein intake now finally let's look at the options here starting with the category incontinence care so what are we going to do for nursing actions well the first option is correct the wound is in an area which can be contaminated with feces in addition to routine incontinence care additional measures should be in place to avoid Fingal contamination in that wound so yes we have to protect the wound and avoid contamination now the next option routine incontinence care should occur is wrong and here's why it requires frequent not just routine care now let's move on to pain the first option is correct the nurse should evaluate for pain and treat accordingly how about the next one here pressure injuries are not painful and do not require Comfort measures well no that's completely wrong stay AG three dorsal glal wounds are likely to be very uncomfortable so we can't choose that one now moving on to hydration here are we going to choose the first option well this is inaccurate information extra hydration for this client is not required when actually it is so we have to choose the next option remember hydration is critical for overall skin Health it increases oxygen as well as nutrients to the skin and promotes skin strength oh this next one is a SATA question and you know what they say SATA is just one letter away from Satan all right guys let's break this question down the question's asking us to select statements that indicate teaching has been successful the problem here is correct teaching about pressure injury so for the solution before looking at the options think about important teaching for pressure injuries well number one proper hygiene and Wound Care number two is avoid prolonged pressure for example being in bed or in one place for too long and number three think about the importance of nutrition we always increase fluids and increase protein so now let's look at the options here option one shows a statement that I should avoid staying in the same position for more than 2 hours well yes this is good it helps prevent excess pressure that can lead to skin breakdown how about the next one here I'm going to consume a diet higher protein and vitamin C yes the key term here is protein it facilitates when Moon healing how about option three here my bed lens should remain dry and wrinkle-free of course this decreases the risk for friction and shearing forces that can damage the skin now the next option is incorrect it is acceptable to limit fluids no we want to increase fluid as well as protein to protect the skin now the last option is incorrect here sitting on Hard surfaces like a hard chair is best treatment for my pressure injury no we want to avoid hard surfaces this can cause increased pressure and can further damage existing pressure injuries so in this question we need to complete the following sentence by choosing from the list of options the problem is ambulation using a cane and a two-point gate pattern oh snap all right so for the solution before you dive into the options and get super confused always slow it down so number one think about ambulation with a cane and twoo gate pattern so we're going to use the cane on the stronger side of the body remember the cane comes first and then number two remember with the stairs we always go up with the good leg or basically the healthy leg and then down with the bad leg the injured leg so now let's look at the question here the nurse evaluates that the client is using the cane correctly when the client holds the cane on the blank side and advances It Forward while simultaneously taking a step with the blank so now let's look at the options here we want the client to use the cane on the strong stronger side so yes option number one would be correct always remember cane comes first on the stronger side now the rest of the options for response one is incorrect because the weaker side is not the thing to do it's always the stronger side now how about the next one the effected side H I hate when the enx does this because the same thing is saying the weaker side so remember we have to be on the stronger side okay so now that we know response number one we're using the cane on the stronger side now we advance it forward while simultaneously taking a step with the blank so the correct option here is the stronger leg so yes this is correct remember strong leg has the cane and Cane comes first with that stronger leg now the rest of the options are incorrect because the cane does not Advance with the weaker leg and it doesn't Advance with the affected side same thing is saying the weaker side waa head to the link in the description below for way more ngn rationals just just like this all right let's dive into this question we're being asked to click to highlight the findings that require immediate followup so simply think safety the problem here is the client is requiring an NG tube for feedings so for the solution before looking at the options think of two things that can kill or harm the client with NG tube feedings well number one we always verify placement before feeding the worst possible scenario is that tube gets dislodged from the stomach and now fills up the lungs with feeding you can simply kill your client that way and number two is the huge risk for aspiration now let's look at the big chunk of information here so as we scroll through the case study look at the key CH here the client is supine at 10° guys that's a huge risk for aspiration the client should be in fowers or at least High fowers position with the head of the bed elevated now scrolling down 200 mls of gastric aspiration was noted and reintroduced to the client and 60 MLS of interal feeding solution was administered so we definitely need to highlight this cuz it's concerning finding so fancy words for the interal feeding was administered and the residual showed 200 mls so we should hold the feeding and we need to report this to the hcp now the next thing we're going to highlight is the nasogastric tube was flushed with 10 MLS of tap water at completion now the reason we're highlighting it is because we're not administering 10 MLS we have to flush with 30 to 60 MLS of water and don't let the tap water distract you on the enlex the water can be tapped all right another complicated question let's make it simple here for each nursing intervention below click to specify if the intervention is appropriate for clients with peripheral Venus disease Peripheral arterial disease or baricos veins now each intervention May support more than one disease so the problem here is interventions for vascular diseases now for the solution before looking at the options what do you know about vascular disease well number one we have to promote circulation so think p a let the name help you you have to hang the leg to provide circulation and for PVD you simply use the V to elevate the leg also consider smoking sensation or basically stop smoking and weight reduction okay now finally let's dive into the options starting with PVD that peripheral Venus disease are we going to place the leg in a dependent position to relieve pain no because remember PVD you have to elevate the leg what about promoting weight reduction well of course that's always a good choice on the enlex but in this case it reduces strain on the cardiovascular system and improves blood flow what about elevating the leg four to five times a day yes let the name help you elevating the leg with PVD how about applying anti-embolism stockings as prescribed yes of course this actually helps prevent clots in deep veins how about the last one here encourage tobacco sensation so basically stop smoking yes this is always a good choice on the enlex tobacco impairs the vessels by constricting and impairs or slows blood flow now let's move on to p a Peripheral arterial disease are we going to place the leg in a dependent position to relieve pain yes of course because let the name help you p a weang the leg basically dangle the leg this actually promotes circulation down to the toes what about the next one promote weight reduction of course this is always a good choice on the enlex to reduce weight how about elevating the legs four to five times throughout the day no that is only for PVD or Venus issues what about applying anti-air embolism stockings as prescribed no we don't want to do that because we have an arterial problem and what about the last one tobacco yes stop tobacco so these ones should always be correct remember weight and tobacco reduction is always encouraged on on the enkin now lastly is varico veins are we going to place the legs in dependent position to relieve pain no let the name help you the key term is veins so remember veins you elevate the legs and there it is again promoting weight reduction of course how about elevating the legs four to five times a day yes let the name help you it's a Venus condition so we Elevate what about applying anti-embolism stockings as prescribed yes of course extra squeeze helps to actually relieve the symptoms and the very last one stopping smoking is always a good choice okay last question for today's video coming right up and if you can't get enough of these then you can get way more by just clicking the link in the description below now for the infamous bow tie questions which can be really complicated but let's make it simple so the question's asking us to complete the diagram by dragging the choices to identify number one the condition number two the actions to address the condition basically how are we going to save the client's life life and number three parameters to monitor for to keep the client safe now in terms of the problem here let's look at the case study and find the key words that risk safety so starting at the top we see the client is admitted for shortness of breath which could be anything so let's click under tab number one and see what we find so we see shortness of breath which we already knew as well as respiratory distress when ambulating fancy words for when walking next we see a mild cardio infarction or basically an Mii heart attack about 1 month ago simply think Mi heart muscles die leading to heart failure the next finding is the client is unable to get his medication so that's not good as well as ibuprofen is used for pain remember ibuprofen is an nsid and on the enlex nids are not good for the body especially for heart failure cuz it actually worsens heart failure the next finding is ronai in the lungs this simply means lung fluid so simply think HF for heart failure we have HF heavy fluid in the body clients can actually drown in their own fluid now look at this next key term S3 gallon this is just fancy words for a heart murmur and it may be from the heart attack because remember Mi heart muscles die the next key term is three plus pitting edema in the legs remember edema is simply that water bed skin because again HF for heart failure we see HF heavy fluid in the body now let's look at the Vital Signs and oh boy these are all messed up the blood pressure is super high 159 over 88 so that is really high because again heavy fluid with heart failure heart rate is up at 110 the respiratory rate is at 26 but take a look at this oxygen saturation it's at 92% on room air and it's probably from all that lung fluid and the temperature is fine so now that we have all this info simply stop and think think about what kills the client first well think HF for heart failure we have HF heavy fluid in the body the lungs are filling with fluid and the client is likely to drown in their own fluids now let's click over to tab number two and see the labs the first thing we see is a BNP of 845 holy guacamole now this case study is nice cuz it gives us the normal range but look at that normal range it maxes out at a 100 so use the memory trick BMP is just bulging ventricles bulging from all that heavy fluid inside the heart with heart failure because the heart has failed as a pump so we can't pump blood or even fluids forward the next thing we see is an echo or an echo cardiogram and it's at 35% normally it's above 50% so an echo means that the heart is pumping out less blood to the body and remember HF for heart failure the heart is failing as a pump so we see HF heavy fluid inside the body so for the solution we have a lot of information here so before looking at the options and getting confused what do you know about the data findings always think what kills or harms the client first so remember HF for hard failure is HF heavy fluid in the body and let the case study help you look at those key terms that we just identified Mi heart muscles die so the heart fails as a pump the Ron ey in the lower lungs is simply lung fluid from all that heavy fluid from heart failure three plus pitting edema in the legs we have edema that water bed skin so the entire body is filling with water as well as the high blood pressure from heavy fluid and 92% of oxygen on room air probably from that high fluid and BMP is at 845 and the echo is low at 35% woo now all that information points us to option number one heart failure because of course it must be heart failure with all that heavy fluid based on all the details we just mentioned now the rest of the options are incorrect and I can explain why in option two ARS is simply hard lungs now it's due to fluid overload in those lung sacks those alvioli but it's more present with infection which we don't see here also extreme shortness of breath and our client only has minor shortness of breath now option three is incorrect because cardiogenic shock simply think s for shock s for severely low blood pressure and our client here has high blood pressure actually really high blood pressure now option four is incorrect because a pulmonary embolism or a PE is simply a blood clot in the lungs and these clients have severe chest pain and extreme shortness of breath which our client doesn't have okay now in terms of actions before looking at the options think about the data in the case study then think about actions that are going to save the client's life so we know the client has heavy fluid in the body so what action are you going to take okay now let's look at the options here so option number one is is correct the client has heart failure that heavy fluid in the body so we definitely need to Monitor and limit that water intake how about option number two discontinue ibuprofen which is an nsid remember nids are not good for heart failure it's going to make it worse so option two is also correct how about option three well this one is definitely incorrect limiting sodium intake to 5,000 a day what no that is not a limit at all that's actually an excess a true limit is is no more than 2,000 mg or simply 2 g a day how about option four giving oxygen well yes this is correct look at the client's O2 set it's at 92% so we definitely need to give oxygen to boost it up now the last option is incorrect because again with the excess 5 L of water is way too much that's nearly 1.5 gallons we need to limit that fluid because the client already has heavy fluid in the body so limiting it to 2 L Max per day okay now very lastly the parameters to monitor for so once again before looking at the options think about the data in the case study what would you monitor for to keep the client safe well number one is daily weights because remember that heavy fluid in the body number two is that dangerously high blood pressure and then I'm thinking about the BNP okay now let's look at the options here option one is correct simply remember weight gain equals water gain and remember these key numbers for the en clix 2 to 3 l pounds of weight gain in 24 hours we must report this to the hcp because the client can die from the fluids in their lungs now the next two options are incorrect because in option two this one was a close one but it's wrong because there's no indication of hypoxia in the data shown and we'd expect the lab values to show this and there's no indication of severe lung or metabolic issues here now option three is also incorrect because x-ray of the legs no on the enlex this is mainly for Brook broken bones now what about option number four strict eyes and O's well remember HF for heart failure think HF heavy fluid in the body so this is correct we want to monitor very closely what goes in and what comes out now option five is incorrect musculoskeletal function no we have a mucho fluid problem not a musculoskeletal problem so no the problem is not in the bones or even the muscles here the only problem is in the heart muscles not pumping right and now fluid backs up into the body wow NG questions are no joke but you're doing great get access to way more ngn questions plus all of this and you can sign it for free by simply clicking the link in the description below

Channel: Simple Nursing

Views: 110,012

Keywords: nlcex, nlcex exam, ncex, enclex, ngn, nextgen, nextgen nclex, nextgen nlcex

Id: EQ4E86mmcLU

Length: 27min 47sec (1667 seconds)

Published: Wed Jan 17 2024