2023-2024

ULTIMATE
NEXT GEN
NCLEX
STUDY GUID UIDE
All you need to
know about
CJMM Steps
Case studies

NCLEX NGN Question Types

LAB Values and many
more!

CHANGES!

T G E N P R A C T I C E
NEX
EXAMS INSIDE!

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 Are you ready Top 5 Skills Required
for NCLEX
Changes? to Practice Nursing

WHY IS THE CLINICAL JUDGEMENT

NCLEX CHANGING?
2
NGN was developed to strengthen
the linkage between test items and PROBLEM SOLVING
clinical judgment using the Clinical
3
Judgment Model.
CRITICAL - THINKING

PUBLIC SAFETY 4

50% of novice nurses had errors.

ACTIVE LISTENING

65% of the errors were related to 5

some poor judgement of either
a task or an environment. PROFESSIONAL
COMMUNICATION

20% of employers believed they

received novice nurses who
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were effectively prepared to
make clinical decisions.
 ReMarNurse.com

The Clinical Judgment Measurement Model (CJMM) is what the new NCLEX is built on.
Each layer represents the thought process needed to make a correct clinical judgment about a
client who needs nursing care.
Layer 0 represents the nurse determining the client's needs.
Layer 1 represents the entire process of clinical judgment.
According to the client response in layer 2, the nurse then moves through layers 3 and 4.
Layer 3 is the area where testing can take place to determine the education of entry-level
nurses and how they develop clinical judgment over a period of time. The six steps within layer 3
make up a repetitious process the student can improve over time with nursing experience and
clinical exposure. This is considered the “action layer.” Layer 4 creates a realistic client scenario.
The CJMM is appropriate for use in the lab setting, clinical setting, and on a standard written or
computer examination.

Client Clinical
Needs Decisions

Layer 0

Clinical Judgment
Layer 1 Satisfied

Not satisfied

Form Hypotheses Refine Hypotheses Evaluation

Layer 2

Recognize Analyze Prioritize Generate Take Evaluate

Cues Cues Hypotheses Solutions Actions Outcomes

Layer 3
Environmental Factor Examples Individual Factor Examples

Client Medical
Environment Resources Knowledge Skills
Observation Records Specialty

Consequences Time Task Cultural Candidate Prior Level of

& Risks Pressure Complexity Consideration Characteristics Experience Experience

Layer 4

Nursing
Assessment Analysis Planning Implementation Evaluation
Process

THE NCSBN CLINICAL JUDGMENT

MEASUREMENT MODEL
The “Action Layer of Layer 3” has 6 steps that are important for nursing
students to memorize and understand. Layer 3 is how Case Studies are written.
Review the graph below. There are expected steps that a nursing student must
take based on the information that is presented. Each case study will have 6 ReMarNurse.com
questions as a part of an unfolding case.

Cognitive Operations Factor Conditioning Expected Behaviors /

(NCSBN CJMM Layer 3) (NCSBN CJMM Layer 4) Actions

Environmental cues:
STEP 1
Location : Emergency
RECOGNIZE CUES Department

Parent present

Client observation cues:

Recognize signs/symptoms of
Present age: 8-10 years
dehydration
Present: sign/symptoms of
Identify history of diabetes
dehydration: dry mucous
membranes, cool extremities, Recognize abnormal vital signs
capillary refill 3-4 seconds
Present/imply: lethargy Hypothesize dehydration
Hypothesize diabetes

Medical record cues:

Present/imply: Hx of diabetes
Present/imply: Vital signs

Time pressure cues:

Set time pressure to vary with
onset/acuity of symptoms

STEP 2 Requires knowledge of

pediatric development Describe relationship between
ANALYZE CUES level of blood sugar and
Requires knowledge of
dehydration
dehydration symptoms
Use evidence to determine
Requires knowledge of client issues
diabetes symptoms
 ReMarNurse.com

Cognitive Operations Factor Conditioning Expected Behaviors /

(NCSBN CJMM Layer 3) (NCSBN CJMM Layer 4) Actions

STEP 3 Give vital sign monitors as

resources
PRIORITIZE HYPOTHESES
Set time pressure to
vary with vital signs Prioritize dehydration

Address dehydration
Requires knowledge of
STEP 4
pediatric developmentally Avoid glucose
GENERATE SOLUTIONS appropriate approach
Requires knowledge of
dehydration treatment and
intervention

Requires knowledge of
diabetes treatment and
intervention

STEP 5 Experience:
TAKE ACTIONS Requires experience of Administer isotonic fluid
administering isotonic fluid

STEP 6 Experience:
Requires experience of
EVALUATE OUTCOMES administering isotonic fluid
Reassess vital signs
Client observation cues:
Reassess lethargy
Show client awake and talking

Imply improvement in vital

signs based on actions
CONGESTIVE HEART FAILURE
CASE STUDY
REPORT A 65 years old male client is admitted to cardiopulmonary unit with a
diagnosis of congestive heart failure. During admission in ER the client
reported dyspnea, easily tires when completing a task, swelling in the
legs, feet and ankle, history revealed that the client is a known smoker
and with hypertension on medication. During rounds in the unit bilateral
pedal edema +2 is noted, nasal flaring and used of accessory muscles
when breathing noted. Upon checking vital signs, it is noted that the BP
is 165/100 mmHg.

LABORATORY Brain natriuretic peptide (BPN) level 450 pg/mL

RESULTS CK-MB 10 IU/L
Troponin I 0ng/mL
Na 140 mmol/L
K 5.0 mmol/L
Cl 103 mEq/L
DIAGNOSTIC ECG – abnormal findings
TEST Echocardiogram – Systolic dysfunction
IMPRESSION/ Chest X-ray interpretation - cardiac silhouette enlargement with
RESULT
secondary findings of congestive heart failure.

MEDICATION Digoxin 0.25 mg P0 0D

Furosemide 20 mg IV q8
Metoprolol 50 mg BID P0

ReMarNurse.com
 CONGESTIVE HEART FAILURE
CASE STUDY

PRACTICE EXAM
QUESTION #1
Among all the signs and symptoms manifested by the client, identify which 3 assessment findings is
mostly expected. Select N that apply.
☐Dyspnea
☐Fatigue
☐Bilateral pedal edema +2
☐Blood pressure 165/100 mmHg
☐Fever

QUESTION #2
For each assessment check to classify if the finding is HELPFUL or Not HELPFUL in diagnosing CHF
in client.
Diagnostic / Laboratory results Helpful Not Helpful
Brain natriuretic peptide (BPN) level 450 pg/mL ☐ ☐
CK-MB 10 IU/L ☐ ☐
Echocardiogram – Systolic dysfunction ☐ ☐
Troponin I 0ng/mL ☐ ☐
Na 140 mmol/L ☐ ☐
ECG – abnormal findings ☐ ☐
K 5.0 mmol/L ☐ ☐

QUESTION #3
Relate one condition and two assessment to fill in each blank of the following sentence.
The client is at highest risk for as evidenced by the
condition
client's and
assessment 1 assessment 2

Conditions Assessments
☐Decreased cardiac output ☐ Dyspnea
☐Ineffective airway clearance ☐ Edema
☐Risk for injury ☐ BP 165/100 mmHg
☐Ineffective breathing pattern ☐ Fatigue
ReMarNurse.com
 CONGESTIVE HEART FAILURE
CASE STUDY

PRACTICE EXAM
QUESTION #4
Check the anticipated provider orders from each of the following categories:
Each category have 2 potential orders.

Categories Anticipated Orders

Diet ☐Low sodium diet
☐High protein diet
☐High fiber diet

Activity / Restrictions ☐Avoid strenuous activity

☐Complete bed rest with bathroom privileges
☐Aerobic activity with rest periods

Monitoring ☐Blood pressure

☐Oxygen saturation
☐Pulse rate

QUESTION #5
For each possible intervention check to evaluate if the intervention is ESSENTIAL or
CONTRAINDICATED.

Possible interventions Essential Contraindicated

IV fluids ☐ ☐
Diuretics ☐ ☐
NSAIDs ☐ ☐
Vasodilators ☐ ☐
Cardiac glycosides ☐ ☐

ReMarNurse.com
 CONGESTIVE HEART FAILURE
CASE STUDY

PRACTICE EXAM
QUESTION #6

Highlight the findings that indicate the client is ready for discharge.

Nurses notes:
The client’s vital signs has been constantly within normal range, also the client did not report further episodes of
dyspnea. The client stated that he was able to sleep at least 7 hours per night and that he has regained his
appetite. The client also stated that he is learning to watch for changes in his heart rate, blood pressure and
weight. Also, he agreed to limit his sodium intake to improve his condition.

- answer key at the back of the packet -

Next Gen NCLEX Question Types

You Must Know ReMarNurse.com

12 NGN UNFOLDING ITEM TYPES

Extended Multiple
Highlight Drag & Drop Drop Down Matrix/Grid
Response
Text Cloze Cloze Multiple SATA
Table Rationale Rationale Response SNTA
Table Multiple Choice Grouping
STAND-ALONE ITEM TYPES
Trend Bow-tie
 EASY NCLEX LABS ReMarNurse.com

LABS VALUES
Hgb male: 14-16.5 g/dl
female: 12-15 g/dl

male: 4.5-6.2 %
RBC female: 4-5.5 %

male: 41-51 %
Hematocrit female: 36-46 %
*This number increases with DEHYDRATION

WBC 5,000-10,000 uL or mm3

K 3.5-5.1 mEg/L
Na 135-145 mEg/L
Ca 8.6-10 mEg/L
Mg 1.6-2.6 mEg/L
C1 95-105 mEg/L
CO2 22-32 mEg/L

BUN 8-25 mg/dL

0.6-1.3 mg/dL
Creatinine
*High creatinine signals renal failure

Liver Enzymes 1. 10 to 40 IU/L

2. 5-35 U/L
1. aspartate aminotransferase
(AST) or (Sgot)
*This number increases with
2. alanine aminotransferase HEPATITIS and JAUNDICE
(ALT) or (Sgpt)

Glucose 70-110 mg/dL

Clotting should occur in 30-45 seconds.
aPTT Blood thinners will make value 1.5-2 times longer.

INR (international normalized ratio) 1-2

Urine specific gravity 1.016-1.022

Platelets 150,000-400,00 uL

What common medication will quickly

Aspirin
disrupt platelet function?
 REMAR DRUG CARDS
CLASS: NITRATES
THERAPEUTIC USES:
ADVERSE EFFECTS:
Decreases myocardial oxygen consumption.
Decreases preload with venous pooling. Headache, lightheadedness, dizziness, flushing,
Decreases afterload by decreasing peripheral vascular orthostatic hypotension, reflex tachycardia, edema.
resistance.
NURSING CARE & TEACHING:
Sit down when taking, change positions slowly, keep tablets away from light, moisture, and body heat; change tablets every 6 months rotate site
of ointment or patch; remove ointment or patch and clean skin for daily nitrate-free period for acute angina: take 1 tablet sublingual (or 1 spray
under the tongue) every 5 minutes up to three doses; seek emergency treatment if there is no pain relief.
Warn clients not to take sildenafil (viagra), vardenafil (levitra), or tadalafil (cialis) within 24 to 36 hours of taking nitrates (combination will cause
a dangerous drop in blood pressure).

MUCOLYTICS
GENERIC NAME: Mycomyst
CLASS:
SAFE DOSE: 70 mg/kg by mouth every 4 hours for 17 doses; may be given by nebulizer, intratracheal or nasogastric.

THERAPEUTIC USES: ADVERSE EFFECTS:

Acetaminophen overdose. Bronchospasm, hypersensitivity reaction.
Acute and chronic bronchopulmonary disease, tracheostomy
care, pulmonary complications of cystic fibrosis.

NURSING CARE & TEACHING:

When using for acetaminophen poisoning – give as direct instillation via nasogastric tube into stomach.
Other uses give as nebulizer.

ANTI-TUBERCULARS
GENERIC NAME: Isoniazid
CLASS:
SAFE DOSE: 5 mg/kg up to 900 mg PO/IM daily for 6 to 18 months

THERAPEUTIC USES: ADVERSE EFFECTS:

Agent that interferes with DNA of M. tuberculosis. HEPATOTOXICITY, agranulocytosis, aplastic anemia,
thrombocytopenia.

NURSING CARE & TEACHING:

Take on empty stomach.
Advise client to also take pyridoxine (vitamin B6) to help prevent peripheral neuropathy.

GENERIC NAME: Cromolyn nasal (nasalcrom)

CLASS: MAST CELL STABILIZER
S A F E D O S E : 1 spray each nostril 3-4 times/daily

THERAPEUTIC USES: ADVERSE EFFECTS:

Allergic rhinitis. Nasal burning, epitaxis, sneezing, bronchospasm.

NURSING CARE & TEACHING:

Will take up to one week to see improvement of symptoms.
 REMAR DRUG CARDS
GENERIC NAME: Zafirlukast (accolate), montelukast (singulair)
CLASS:
LEUKOTRIENE-RECEPTOR ANTAGONISTS
THERAPEUTIC USES: ADVERSE EFFECTS:
Asthma and exercise induced bronchospasm. Angioedema, anaphylaxis, erythema nodosum, aggressive
behavior, hallucinations, depression churg-strauss syndrome.

NURSING CARE & TEACHING:

Monitor respiratory status.
Give 2 hours before meals.
Report any changes in urinary patterns.

GENERIC NAME: Phenobarbital, primidone (mysoline)

CLASS:
BARBITURATES

THERAPEUTIC USES: ADVERSE EFFECTS:

Seizure disorder, essential tremors, status epileptics, Life-threatening: respiratory depression, erythema
medical induced sedation. multiforme, stevens-johnson syndrome, angioedema,
megaloblastic anemia, TTP, blood dyscrasias, suicidality.

NURSING CARE & TEACHING:

Monitor respiratory status.
Monitor signs of depression and suicide.
Therapeutic drug level: 10-40 mcg/mL.
Do not give to elderly or clients with impaired renal function.

GENERIC NAME: Ethosuximide (zarontin)

CLASS: SUCCINIMIDES
S A F E D O S E : 250 mg by mouth twice daily

THERAPEUTIC USES: ADVERSE EFFECTS:

Absence seizures. Anorexia, dyspepsia, nausea, vomiting, abdominal pain,
weight loss, lupus erythematosus, paranoid psychosis.

NURSING CARE & TEACHING:

Therapeutic drug levels: 40-100 mcg/mL (toxic level > 150 mcg/mL).
Monitor for signs and symptoms of depression, behavior changes, suicidality.

GENERIC NAME: Ropinirole (requip, requip XL), bromocriptine (cycloset, parlodel), amantadine (symmetrel)
CLASS:
DOPAMINE AGONISTS
THERAPEUTIC USES: ADVERSE EFFECTS:
Parkinson disease, extrapyramidal disorders, neuroleptic Heart failure, arrhythmias, cardiac arrest, psychosis,
malignant disease, hyperprolactinemia, acromegaly- coma, respiratory failure, pulmonary edema
replacement therapy to increase dopamine levels. most common: nausea, dizziness, insomnia, depression,
anxiety, irritability, hallucinations, confusion.
NURSING CARE & TEACHING:
Wear MedicAlert® identification.
Taper off drug.
Do not give to clients with impaired renal function.
 REMAR DRUG CARDS
GENERIC NAME: Benztropine (cogentin) –give in evening, trihexyphenidyl (artane)
CLASS:
ANTICHOLENERGICS
THERAPEUTIC USES: ADVERSE EFFECTS:
Decreases excess cholinergic effect of dopamine deficiency ***Hyperthermia, heat stroke, neuroleptic malignant
by competing with acetylcholine for muscarinic receptor syndrome, tardive dyskinesia most common:
sites, parkinsonism. xerostomia, blurred vision, dizziness, nausea, anxiety,
confusion.
NURSING CARE & TEACHING:
Do not give with angle-closure glaucoma.
Taper off drug.
Give with food.

GENERIC NAME: Cyclobenzaprine (amrix, fexmid, flexeril), carisoprodol (soma)

CLASS:
SKELETAL MUSCLE RELAXING AGENTS
THERAPEUTIC USES: ADVERSE EFFECTS:
Muscle spasms, acute musculoskeletal pain. Seizures, cardiac conduction disturbances, arrhythmias,
myocardial infarction, stroke, heat stroke drowsiness,
dry mouth, dizziness fatigue, headache, constipation,
NURSING CARE & TEACHING: hepatitis.
Taper off drug.
Avoid abrupt withdrawal.
Do not give with MAOI.
Change position slowly after taking due to dizziness.

GENERIC NAME: Etanercept (enbrel)

CLASS: BIOLOGICS

THERAPEUTIC USES: ADVERSE EFFECTS:

Inflammation-ankylosing spondylitis, moderate-to-severe Serious infection, sepsis, opportunistic infection,
chronic psoriasis plaque, psoriatic arthritis, mod-severe tuberculosis, malignancy.
rheumatoid arthritis.

NURSING CARE & TEACHING:

Do not give if client is sick or immunosuppressed.
Do not give at the same time as live vaccinations.
Administer a tuberculin skin test prior to start of treatment--make sure client does not have cancer.

GENERIC NAME: Ethylenediaminetetraacetic acid (EDTA), penicillamine (cuprimine)

CLASS:
CHELATING AGENT
THERAPEUTIC USES: ADVERSE EFFECTS:
Binds to metals and poisons (ex. lead, mercury) arsenic. Thrombocytopenia, leukopenia, aplastic anemia,
anorexia, epigastric pain, nausea, vomiting, diarrhea.

NURSING CARE & TEACHING:

Do not use with gold salts.
Do not give if sensitive to PCN.***
Do not give during pregnancy.
Give on empty stomach.
Take temperature at bedtime.
 REMAR DRUG CARDS
GENERIC NAME: Probenecid (benemid)
CLASS: ANTI-GOUT MEDICATIONS

THERAPEUTIC USES: ADVERSE EFFECTS:

Helps reduce uric acid levels. Anemia, liver damage, N&V, vomiting sore gums, urinary
Gouty arthritis. frequency.
NURSING CARE & TEACHING:
Do not give if creatinine clearance is less than 50. Do not give with NSAIDs.
Do not give if client already has kidney stones. Client should drink 2-3 liters of fluid daily.
Client has to follow low purine diet.
Do not abruptly stop medication.
Start with the lowest dose.

GENERIC NAME: Permethrin topical (nix, elimite)

CLASS:
ANTI-SCABIES, LICE KILLER

THERAPEUTIC USES: ADVERSE EFFECTS:

To get rid of body critters. Burning, pruritus, erythema, numbness and tingling.

NURSING CARE & TEACHING:

Wear gloves when administering this medication.
Avoid eyes, face, and mucous membranes.
All clothes/bedding needs to be washed in hot water.
Teach clients itching can still last for up to 6 weeks.
Do not give to infants.

GENERIC NAME: Metronidazole topical (metro cream), ketoconazole topical (extina, nizoral A-D, nizoral topical, xolegel) selenium sulfide topical
CLASS: (selsun, selsun Blue)
ANTI-FUNGALS (Topical meds for the skin)

THERAPEUTIC USES: ADVERSE EFFECTS:

Acne rosacea, tinea corporis pedis, versicolor, and cruris; Skin irritation, hair loss, hair discoloration.
seborrheic dermatitis, dandruff/seborrhea.

NURSING CARE & TEACHING:

Wash skin thoroughly.
Wear gloves when applying this medication.
Client may need to wear sunscreen.
Call physician if sore throat, fever, or rash develops.

GENERIC NAME: Metoclopramide (metozolv, reglan)

CLASS:
ANTI-EMETIC, CHOLINERGIC/DOPAMINE BLOCKER
THERAPEUTIC USES: ADVERSE EFFECTS:
GERD, nausea, vomiting. Extrapyramidal symptoms, acute dystonia, parkinsonism,
tardive dyskinesia, neuroleptic malignant syndrome.

NURSING CARE & TEACHING:

Do not confuse with methotrexate or metolazone (zaroxolyn).
Do not give if client has GI bleeding.
Report symptoms of involuntary movements.
 REMAR DRUG CARDS
GENERIC NAME: Magnesium citrate, magnesium hydroxide (milk of magnesia, phillips' milk of magnesia), magnesium sulfate
CLASS:
MAGNESIUM SALTS
THERAPEUTIC USES: ADVERSE EFFECTS:
Constipation, bowel prep, hypomagnesemia, ventricular Nausea, vomiting, anorexia, cramps,
arrhythmias, preeclampsia seizures, tocolysis. **depressed reflexes, may cause respiratory
depression.

NURSING CARE & TEACHING:

Calcium gluconate is the antidote.
Monitor for depressed reflexes.
Signs of magnesium toxicity, i.e., thirst, confusion, hyporeflexia.

GENERIC NAME: Aluminum hydroxide gel (alternagel, amphojel)

CLASS:
ALUMINUM SALTS
THERAPEUTIC USES: ADVERSE EFFECTS:
Binds to phosphorus. Aluminum intoxication, osteomalacia, encephalopathy,
constipation, hypophosphatemia, abdominal pain.

NURSING CARE & TEACHING:

Avoid foods containing phosphorus such as dairy products, eggs, and carbonated beverages.
Report decreased reflexes.

GENERIC NAME: Bismuth subsalicylate (kaopectate)

CLASS:
ANTIDIARRHEAL AGENTS
THERAPEUTIC USES: ADVERSE EFFECTS:
Binds to phosphorus. Encephalopathy, reye syndrome, blackened stools and
tongue, constipation, tinnitus.

NURSING CARE & TEACHING:

Do not give if client is pregnant 2 or 3 trimester.
Do not give if client has renal failure or GI bleed.
G6PD deficiency contraindicated-red blood cell disorder more common in males.
Give 2 hours before any other oral medications.

GENERIC NAME: Sulfasalazine (azulfidine), mesalamine (apriso, asacol, liada, pentasa)

CLASS:
INFLAMMATORY BOWEL REDUCERS
THERAPEUTIC USES: ADVERSE EFFECTS:
Ulcerative colitis, crohn's disease. Neuropathy, interstitial nephritis, renal failure,
hepatotoxicity.

NURSING CARE & TEACHING:

Do not give if client is allergic to salicylates.
Store in airtight, light-resistant container.
Teach client to avoid direct sunlight when taking this medication.
 REMAR DRUG CARDS
GENERIC NAME: Levothyroxine (levothroid, levoxyl, synthroid, tirosint, unithroid), liothyronine (cytomel, triostat)
CLASS:
THYROID AGENTS
THERAPEUTIC USES: ADVERSE EFFECTS:
Hypothyroidism, myxedema. tachycardia, headache, irritability, nervousness, tremor,
diaphoresis, diarrhea, vomiting.

NURSING CARE & TEACHING:

Avoid iodine rich foods such as seafood, fish liver oils, and iodized salt.
Avoid stimulants, caffeinated beverages.
Must take single dose with full glass (8 ounces) of water on an empty stomach.

GENERIC NAME: Potassium iodide (iosat, SSKI, thyrosafe, thyroshield)

CLASS:
IODINE SOLUTIONS
THERAPEUTIC USES: ADVERSE EFFECTS:
Pre-op thyroidectomy, thyrotoxicosis. Arrhythmias, GI bleed, angioedema
parotitis, goiter, thyroid adenoma, metallic taste,
dyspepsia, urticaria.

NURSING CARE & TEACHING:

Do not abruptly.
Wear MedicAlert® identification.
Avoid iodine rich foods.

GENERIC NAME: Vasopressin (pitressin), desmopressin acetate

CLASS:
POSTERIOR PITUITARY AGENT
THERAPEUTIC USES: ADVERSE EFFECTS:
Diabetes insipidus, vasodilatory shock. *hyponatremia,
*water intoxication, seizures.

NURSING CARE & TEACHING:

Wear MedicAlert® identification.
Do not give to clients with cardiac disease, CHF.

GENERIC NAME: Oprelvekin (neumega), aldesleukin (proleukin)

CLASS:
INTERLEUKINS (IL)
THERAPEUTIC USES: ADVERSE EFFECTS:
Inhibit tumor growth in cancer clients. Pleural effusion, pulmonary edema, capillary leak
syndrome, cardiac arrhythmias, anemia.

NURSING CARE & TEACHING:

Monitor for signs of infection.
Do not use aspirin, blood thinners, shaving.
 REMAR DRUG CARDS
GENERIC NAME:
CLASS:
1st generation: Cephalexin (Keflex)
2nd generation: Cefaclor (Ceclor)
3rd generation: Ceftriaxone (Rocephin)
CEPHALOSPORINS
4th generation : Cefepime (Maxipime)

THERAPEUTIC USES: ADVERSE EFFECTS:

Bacterial infections, STDS, PID, UTIs. Anaphylaxis, encephalopathy, seizures, leukopenia
rash, injection site reaction, diarrhea, elevated ALT &
AST, nausea.
NURSING CARE & TEACHING:
Do not give if client allergic to PCN.
Avoid drinking alcohol while taking medication.

GENERIC NAME: Pyrantel (pin-x, pronto plus pinworm treatment, reese's pinworm), albendazole (albenza)
CLASS:
ANTHELMINTIC AGENTS - PARASITIC
WORM KILLERS
THERAPEUTIC USES: ADVERSE EFFECTS:
Pinworms. Abnormal liver enzyme tests, abdominal pain, nausea,
vomiting.

NURSING CARE & TEACHING:

Do not give if the client is pregnant and do not get pregnant for two months after.
Treat all family members.
Avoid tub baths clients need to take showers during treatments.
Take full course of antibiotics.

GENERIC NAME: Streptokinase, alteplase (tPA),tenecteplase

CLASS:
THROMBOLYTIC MEDICATIONS
THERAPEUTIC USES: ADVERSE EFFECTS:
Blood clots (DVT, PE, Ischemic stroke). Increased bleeding, hypotension, allergic reaction.

NURSING CARE & TEACHING:

Give within 4-6 hours of onset.
Use IV aminocaproic acid.
Administer h2 antagonists to prevent GI bleeding.
Do not give if there is a history of intracranial bleeding.

NCLEX ANTIDOTES
DRUG ANTIDOTE

Anticholinergics Physostigmine
Acetaminophen N-acetylcysteine (mucomyst)
Mercury, lead, arsenic Chelation Therapy
Benzodiazepines Flumazenil (romazicon)
Spider bite (black widow) Antivenin
Warfarin Phytonadione, vitamin K
 REMAR DRUG CARDS
GENERIC NAME: Morphine, fentanyl, codeine, oxycodone
CLASS: OPIOID

THERAPEUTIC USES: ADVERSE EFFECTS:

Pain, decreased motility, cough suppression. Respiratory depression, constipation, urinary
retention, orthostatic hypotension.

NURSING CARE & TEACHING:

Do not give if respirations less than 12.
Do not give with other CNS depressants.
NALOXONE (Narcan) is the antidote.

GENERIC NAME: DTaP- Diphtheria, tetanus, pertussis

CLASS: VACCINATION

THERAPEUTIC USES: ADVERSE EFFECTS:

DTaP protection. Seizures, local reaction, encephalopathy.

NURSING CARE & TEACHING:

IM injection.
Do not give if there is a history of encephalopathy.
Given at 2 months.

GENERIC NAME: Methylphenidate (ritalin), adderall, caffeine, dextroamphetamine (dexedrine)

CLASS:
CENTRAL NERVOUS SYSTEM STIMULANTS
THERAPEUTIC USES: ADVERSE EFFECTS:
ADHD, narcolepsy, obesity. Irregular heart rhythms, weight loss, CNS stimulant.

NURSING CARE & TEACHING:

Do not give to clients with hyperthyroidism.
Do not give with MAOIs.
Monitor blood pressure and heart rate.

ReMarNurse.com
 Practice Exam

Trend Item Question Type

Trend item #1
The nurse is caring for a client with CKD stage II. The client's labs values and vital signs
were recorded as below:

Lab Metabolic Panel

Glucose: 85 mg/dL 1 The nurse anticipates

BUN: 14 mg/dL that the client is likely
Creatinine: 1.67 mg/dL having:
eGFR: 54 %
Serum Sodium: 127 mmol/L
Possible Condition
Serum Potassium: 3.4 mmol/L 1. Hypoglycemia with hypotension
Serum Chloride: 93 mmol/L; 2. Hyponatremia with hypotension
Serum Calcium: 8.7 mg/dL; 3. Hyperkalemia with hypotension
8:00 10:00 12:00 4. Hypocalcemia with hypotension
Vital Signs
BP 90/55 80/60 90/50
HR 68 70 68
RR 16 18 18

Physician’s orders were placed, the nurse selects the following intervention
2
to prioritize:

Physician Orders
Monitor vital signs every 15 minutes.
Start with IV line of PNSS and administer 500 cc IV bolus.
Administer NaCl tab BID.
Record fluid input and output.
Administer potassium sparing diuretics.
Encourage low salt and low fat diets.
Insert an indwelling catheter if urine output is <30cc per hour.

ReMarNurse.com
Trend item #2

A 45 year old female client with hyperthyroidism who received a thyroidectomy.

Post-Op Day Nurses Notes

The client is awake and converses but short. She denies painful swallowing and
1 difficulty breathing. Wound dressing is intact, mildly soaked with pink discharge.
The client is afebrile with BP = 110/80; HR = 80; RR = 18.
The client can tolerate short conversation with a weak voice. She reports tingling
2 sensation in her hands and toes. Wound dressing is dry and intact. Vital signs are
stable.
The client can swallow and breath without any difficulty however still having a
3 weak voice. She noticed mild muscle twitching at times. Vital signs are stable.

The nurse relays to the health care provider the persistent findings, which
3
electrolyte is expected to be tested first?
1. Sodium
2. Chloride
3. Calcium
4. Potassium
5. Magnesium
6. TSH

4 In order to absorb calcium faster, the nurse anticipates to give :

Select
Magnesium
Sodium
Calciferol
Potassium

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 Matrix Question Type

5 The nurse is caring for a 33 year old, female client in the Emergency Department
(ED). The nurse is reviewing the entries in the nurses’
notes for the plan of care. For each potential
nursing intervention, check to specify whether the
NURSE’S NOTES:
03/01/2022 intervention is APPROPRIATE or INAPPROPRIATE
0930: A 33 year old multigravida at 37 weeks
for the care of the client.
gestation is seen in the ED. She exhibits Possible Interventions Appropriate Not appropriate
elevated BP of 155/98 mmHg, RR 25 bpm, PR
Maintain fetal monitoring.
79 bpm, Temp 36.1 C, and oxygen saturation
of 96% via pulse oximeter. She has +2 edema Encourage friends and
on both ankles, nauseous and in pain. relatives to remain at their
Presently, she is being treated for severe bedside.
preeclampsia and the health care provider
plans to start a magnesium sulfate infusion
Assess for reflexes, clonus,
at 3 g/hour. visual disturbances, and
headache.
Monitor maternal liver studies
every hour.
Start IV fluids.

6 The nurse is caring for a 34 year old female with suspected placenta previa.

The nurse assesses the client’s findings.

NURSE’S NOTES:
08/02/2022 Check to specify the signs and symptoms that
0700:The client is seen in the ED with her indicate a SIGNIFICANT or NOT SIGNIFICANT
husband. She is a 34 year old, female, gravida 2
para 1, 36 weeks age of gestation, finding related to placenta previa.
experiencing moderate vaginal bleeding but
painless. She is also reported a feeling of
cramping and tightening over her abdomen
Signs & Symptoms Significant Not significant
every 5 minutes. Upon further assessment, Uterine contractions of 5 mins interval
dull lower back pain is noted. Reports of
Painless moderate vaginal bleeding
uterine tetany and intermittent pain with
spotting, none noted. Blood pressure of 133/76 mmHg
Vital Signs checked: Intermittent pain with spotting
BP 133/76 mmHg Dull lower back pain
PR 78 bpm
RR 21 bpm
Temp 36.7 ReMarNurse.com
 7 The nurse is caring for a 23 year old female client in the maternity ward.
The nurse is reviewing the entries in the nurses’ notes
for the plan of care.

NURSE’S NOTES:
07/15/2022 For each potential nursing intervention, check to
0930: specify whether the intervention is APPROPRIATE OR
The client was recently admitted in the NOT APPROPRIATE to maintain safety for this client.
maternity ward for close monitoring. She is
at 15 weeks age of gestation and admitted Possible interventions Appropriate Not appropriate
with dark brown vaginal bleeding and
continuous nausea and vomiting. Her blood Start IV fluids
pressure is 142/98 mmHg, RR 25 bpm, PR 97 Keep the client NPO for 24 hours
bpm, temperature of 37.1 C. Her oxygen Administer magnesium sulfate
saturation is at 97% via pulse oximeter, and
Obtain an ultrasound
her fundal height is 19 cm.
The health care provider is planning for the Start laboratory work up
care of a client with suspected hydatidiform
mole.

8 The nurse is caring for a 52 year old client with myocardial infarction.

The nurse assesses the client’s findings. Check to

NURSE’S NOTES: specify the signs and symptoms that indicate a
8/07/2022
SIGNIFICANT OR NOT SIGNIFICANT finding related
1645: The 52 year old, male client was
recently admitted and diagnosed with
to the client’s condition.
myocardial infarction. Upon routine
assessment, he is restless and agitated, and
Signs and symptoms Significant Not significant
reports low urine output for the day. Oliguria
Restlessness
Vital signs checked BP 85/69 mmHg,
RR 31 bpm, PR 69 bpm, temp 37 C, oxygen Blood pressure 85/69 mmHg
saturation at 95% via pulse oximeter. Temp 37 C
Health care provider notified, and suspects a Decreased urine output
developing cardiogenic shock.

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 Bow Tie Question type
Case #1
The client with a history of anemia and hypertension presented lightheadedness and
intentional weight loss. The nurse took vital signs and documented as below:

Vital signs
Supine: Standing:
T- 36.4C T- 36.7C
P- 102 P- 76
R- 18 R- 18
BP- 140/100 BP- 110/80

Complete the diagram by selecting the choices below to specify what condition the
9 client is most likely to experience, 2 actions the nurse should take to address that
condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Actions to take Potential conditions Parameters to monitor

1. Health teaching on a diet rich in 1. Pernicious anemia. 1. Complete blood count.
folate and B12.
2. Review antihypertensive medication. 2. Orthostatic hypotension. 2. Blood pressure and heart rate.
3. Counsel on physical activity 3. Orthostatic hypertension. 3. Temperature and heart rate.
modification such as rising slowly and
avoiding crossing of legs.
4. Restrict fluid intake. 4. Macrocytic anemia. 4. Blood pressure and temperature.
5. Refer to radiology for brain MRI. 5. Diet and lifestyle.

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Case #2
A 69 year old, female presenting with the following symptoms:
Progress Notes
History of Present illness
A 69 year old female presents to the emergency department secondary to right breast pain and arm swelling. She has a
history of breast cancer in 2016 and had a partial mastectomy at that time. She underwent alternative treatments, not
chemotherapy and radiation. The client admits that over the course of the past year there is been changes to the breast. It is
now contracted erythematous and painful. Her right arm has begun to swell over the past couple of days. She is traveling a lot
and is considering moving to the area. However, she has no contacts here and was very anxious about coming into the hospital.
She is otherwise healthy and takes no medications.
Physical examination
General: Alert, no acute distress. Skin: Warm, dry. Head: Norm cephalic. Neck: Supple. Eye: Pupils are equal, round, and reactive
to light, normal conjunctiva. Ears, nose, mouth, and throat: Oral mucosa moist. Cardiovascular: Regular rate and rhythm, Normal
peripheral perfusion. Respiratory: Lungs are clear to auscultation, and respirations are non-labored. Chest wall: right breast has
been surgically removed. The breast is very contracted with overlying erythema. There is no necrotic tissue present extending
up into the axilla. Musculoskeletal: Normal ROM, normal strength, right arm has some edema and slight erythema, but no warmth
compared to the left. Normal flexion-extension of the wrist with good peripheral perfusion. Gastrointestinal: Soft, non-tender,
non-distended. Neurological: Alert and oriented to person, place, time, and situation. Psychiatric: Cooperative, appropriate mood
& affect.
Reexamination / Reevaluation
Time: 4/28/2018 15:42:00
Notes: A 69 year old female present to the emergency department secondary to right breast pain and right arm swelling. She
has a history of breast cancer. It has occurred with clear visual changes to the right breast. Concern for significantly invasive
malignant carcinoma. She is neurovascular intact but does have demonstrated swelling to the right upper extremity. Ultrasound
does demonstrate a DVT and she is being started on anticoagulation. She seems upset that they cannot just cut out cancer
because she does not want to have it on her chest wall anymore. I explained that she would likely benefit from radiation and
chemotherapy. The case was discussed with a medical oncologist for appropriate follow-up. She had many questions which I
took significant time to answer and offered reassurance and discharged her home.

Complete the diagram by selecting the choices below to specify what condition the client is most likely
10 to experience, 2 actions the nurse should take to address that condition, and 2 parameters the nurse
should monitor to assess the client’s progress.
Actions to take Potential conditions Parameters to monitor
1. Administer oral antibiotics as prescribed. 1. Infectious mastitis. 1. Routine MMG.
2. Provide chemo education. 2. Inflammatory breast cancer. 2. Treatment response from antibiotics.
3. Educate client on meticulous wound care. 3. Breast lymphoma. 3. Molecular genetics.
4. Prepare the client for PET CT. 4. Ductal ectasia. 4. Toxicity check from chemotherapy.
5. Prepare the client for wound debridement. 5. Wound culture and sensitivity.
 Highlight Question Type

The nurse is caring for an 8 year old, male client with a hip spica cast.
11 Highlight the following points of information that should be the most important for
the nurse to consider.

Nurse’s Notes

7/10/2022
0900: During assessment, the client is resting on his bed after brushing his teeth. Vital
signs are within normal limits. The child verbalizes that he cannot play with his toys when
he gets discharged. The mother emphasizes that she will have to make some adjustments
when her kid gets home. She said that the child’s bedroom is on the second floor and
added that his sister offers help in assisting him climbing the stairs at least twice daily.

The nurse is caring for a pediatric client suffering with torticollis.

12
In planning the discharge for a client diagnosed with torticollis, the nurse recognizes
that the client and the mother are ready for discharge. Highlight the text that
supports these statements.

Nurse’s Notes
3/5/2021
0745: The mother of the 4 year old child is anxious regarding the condition of her child. She is
conversant and asks “ What should I do after discharge? How do I take care of my boy?
Health teachings were rendered such as doing gentle exercises daily, coordinating with a physical
therapist, and clinic visits for worsening conditions.

0800: The child finished his meal for breakfast and was moving his upper extremities gently as the
mother assisted. His mother demonstrates passive exercises, and verbalizes “ I think I will see the
physical therapist monthly”.

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 The nurse is caring for a client with chronic hypertension.
13 Highlight the findings below that would indicate the common adverse effects of
clonidine.

Nurse’s Notes

08/01/2022
1835: A 50 year old, male client is admitted for chronic hypertension in the medical ward.
His medication includes clonidine 0.1 mg 1 tablet twice daily. He ate his dinner with ease
and without discomfort. No feeling of drowsiness felt during the whole afternoon.

1940: Client reported hyperventilation, fast and pounding heartbeat, dry mouth and
itchiness over his skin. He is anxious and feeling restless.
Vital signs checked: BP: 158/95 mmHg, PR: 123 bpm, RR: 32 bpm, temp: 37.4 C, oxygen
saturation is at 92%. Referred immediately to Dr. Sans, his healthcare provider for a
possible adverse effect of clonidine.

The nurse is caring for a 10 year old female diagnosed with a brain tumor.
14
Highlight the findings below that would indicate about the client’s condition.

Nurse’s Notes

7/10/2022
0700: A 10 year old female client was seen in the Emergency Department (ED) and was
diagnosed with brain tumor. She was accompanied by her father during the admission
process. The client was fearful and teary eyed as she was holding her long hair. She was
afraid that her hair would be cut off. During the interview, her father verbalizes that
his child has an increasing appetite, a persistent headache that’s worse in the morning,
and acts lethargic, or extra sleepy, for no apparent reason. Upon assessment, the child
is tilting her head, lethargic, and suddenly vomits. The healthcare provider orders a
brain CT scan for the client.

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 Extended Multiple Response
Question Type

15 The nurse is caring for a 28 year old, primigravida client for a prenatal visit.
Nurse’s Notes 0800: A 28 year old, female client, primigravida is seen in the clinic for routine
4/15/2022 prenatal care. Presently, she is at 35 weeks age of gestation, gravida 1 para 0,
and is due for her monthly visit. She reports that she is nervous at the same
time ambivalent about her condition.
Laboratory Hepatitis b surface antigen (HbSAg) - Positive
Which of the following would the nurse suggest regarding the plan of care for the mother
and newborn at birth?
Select all that apply.
☐1. Administration of hepatitis b immune globulin at birth.
☐2. Follow the series of three (3) hepatitis b vaccinations as scheduled.
☐3. Initiate hepatitis screening for her newborn.
☐4. Isolate the newborn after birth.
☐5. Maintain universal precautions for both mother and the newborn.
☐6. Advice to defer breastfeeding because the mother is HbsAg positive.

16 The nurse is caring for a client who is experiencing pain during the first stage labor.
Nurse’s Notes 1145: The client is moved to the labor room for extreme pain. She is at her first
02/17/2022 stage of labor. Her pain scale is at 6/10. Internal examination revealed at 4 cms,
50% effaced cervix, station - 3, intact bag of water.

What the nurse should instruct the client do to manage her pain?
Select all that apply.
☐1. Ambulate in the labor room.
☐2. Have the client do slow chest breathing.
☐3. Request pain medication as needed.
☐4. Massage her abdomen lightly.
☐5. Sip ice water or ice chips.
☐6. Allow her to talk her frustrations and pain.
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17 The nurse is discussing dietary concerns with a pregnant teen.

Nurse’s Notes 1300: A 19 year old, first time pregnant client is at the outpatient department.
07/25/2022 She is interested in proper nutrition during pregnancy. During the prenatal visit,
she asks “ What are the following meal choices that I need to eat?”.
Which of the following choices are convenient for teenagers yet nutritious for both
mother and the fetus? Select all that apply.
☐1. One milkshake or yogurt with fresh fruit or one granola bar.
☐2. Chicken nuggets with tater tots.
☐3. Cheese pizza with spinach and pepperoni topping.
☐4. Peanut butter with crackers and a juice drink.
☐5. Cheesy light popcorn with diet soda.
☐6. Burger with cheese, tomato and lettuce.

18 The nurse is caring for a 35 year old multigravida client in the obstetrics clinic.

Nurse’s Notes 0930: A 35 year old multigravida returns to the clinic for a routine prenatal
08/03/2022 visit at 36 weeks’ gestation. She has had a prior pregnancy with pregnancy-
induced hypertension. The assessments during this visit include BP 150/96 mmHg,
PR 87 bpm, RR 22 bpm, temp of 36.1, with an oxygen saturation of 97% via pulse
oximeter. She also exhibits stomach pain, +2 edema of the ankles and feet.
Furthemore, she reported frequent headaches when working during the day.
Upon checking, she showed the urinalysis test she had the other day that states
Protein: ++
Glucose: negative

Based on the client’s history and assessment, what assessment information should the
nurse determine if this client is becoming preeclamptic? Select all that apply.
☐1. Headache
☐2. +2 edema of the ankles and feet
☐3. Protein:++ in urinalysis
☐4. BP 150/96 mmHg
☐5. Oxygen saturation of 97%
☐6. Stomach pain ReMarNurse.com
 Drag and Drop
Question Type

19 The nurse admitted a client with chief complaints of chest pain and shortness of
breath.
The client is a 45 year old female who followed a weight loss program and
HPI
underwent gastric bypass. The surgery was successful however a week after
the surgery the client went to ED with chief complaints of chest pain. She
reported that she did not move around to avoid too much exertion however she
also experienced fatigue and abdominal discomfort for the past 2 days.
(A) (B)
The client is likely having: persistent with findings :
A B
Myocardial infarction Chest pain and dyspnea
GERD Chest pain, dyspnea and fatigue
Pulmonary embolism Chest pain, dyspnea and calves swelling
Pneumonia Chest pain, dyspnea and abdominal discomfort

20 The nurse is assessing a 32 year old female with chest discomfort.

Presentation The client presented substernal burning which is radiating to the neck and she
reports tasting unpleasant liquid in her mouth. She reports that it worsens when
she bends down or is lying supine. She denies shortness of breath and early satiety.
ECG Report revealed sinus rhythm with occasional premature atrial contractions
(PACs). Normal axis and intervals. No ischemic changes.
(A) (B)
The client is likely having: which can be best controlled with :

A B
Peptic ulcer disease Dicyclomine
Gastroesophageal reflux disease Aluminum hydroxide
Dyspepsia Alprazolam
Gastritis Esomeprazole

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 Practice Exam

Answer Key
1.) 2: Hyponatremia with hypotension
Rationale: The client is experiencing hyponatremia with hypotension. serum sodium : 127 mmol/L (normal range: 134-144 mmol/L) BP : less than 90/60.

2.) Start with IV line of PNSS and administer 500 cc IV bolus.

Rationale: This will hydrate the client and will address the hypotension and hyponatremia.

3.) 3: Calcium
Rationale: There could be temporarily low calcium level following the thyroidectomy, and less commonly, have a persistent low calcium
level d/t the absence of TSH. This may be manifested by tingling sensation in the hands and feet and sometimes around the mouth, and
muscle twitching.

4.) Calciferol
Rationale: Calciferol or vitamin D. enhances the absorption of calcium.

5.) Possible Interventions Appropriate Not appropriate

Rationale: In maintaining the well-being of the maternal-fetal health,
it is a priority that the Central Nervous System (CNS) is properly
Maintain fetal monitoring. X functioning and free from injury. If the mother suffers CNS
Encourage friends and damage related to hypertension or stroke, oxygenation status is
relatives to remain at their X compromised and the well-being of both mother and infant are at
bedside. risk. Continuous fetal monitoring is an assessment strategy for the
Assess for reflexes, clonus, infant and would be of importance to maternal CNS assessment
X because maternal oxygenation will dictate fetal oxygenation and
visual disturbances, and
well-being. In preeclampsia, frequent assessment of maternal
headache.
reflexes, clonus, visual disturbances, and headache give clear
Monitor maternal liver studies X evidence of the condition of the maternal CNS system. Monitoring
every hour. the liver studies does give an indication of the status of the
Start IV fluids. X maternal system but not every hour. Psychosocial care is a priority
and can be accomplished in ways other than having the family remain
at the bedside.

6.) Signs & Symptoms Significant Not significant Rationale: Placenta previa refers to the placental tissue that
covers any portion of the internal cervical os. The most
Uterine contractions of 5 mins interval X
common assessment finding associated with placenta previa is
Painless moderate vaginal bleeding X painless vaginal bleeding. Sudden painless vaginal bleeding often
Blood pressure of 133/76 mmHg X begins; the blood may be bright red, and bleeding may be
heavy, sometimes resulting in hemorrhagic shock. The
Intermittent pain with spotting X
symptoms usually begin during late pregnancy. In some clients,
Dull lower back pain X
uterine contractions accompany bleeding.

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 Practice Exam

Answer Key
7.) Possible interventions Appropriate Not appropriate Rationale: The nurse should prepare the client for an ultrasound
Start IV fluids X to figure out what's causing the symptoms. Elevated blood
Keep the client NPO for 24 hours X pressure at this stage of pregnancy may indicate chronic
hypertension or hydatidiform mole. The fundal height of 19 cm is
Administer magnesium sulfate X
greater than is typical at 15 weeks of gestation and indicates a
Obtain an ultrasound X molar pregnancy (hydatidiform mole). In isolation, dark brown
Start laboratory work up X vaginal bleeding could indicate an abortion, but when combined
with the other symptoms, it is more likely to be a hydatidiform mole. Continuous nausea and vomiting is unusual at this stage of pregnancy and may be
caused by the high levels of progesterone produced by a molar pregnancy. Starting IV fluids is necessary for medication administration, while checking
the laboratory is essential to confirm levels of progesterone. There is no fetus involved; the blood pressure elevation and the continuous nausea and
vomiting will resolve with evacuation of the mole, negating the need for magnesium sulfate therapy and placing the client on NPO status.

Signs and symptoms Significant Not significant Rationale: Oliguria occurs as a result of decreased blood
8.) flow to the kidneys during cardiogenic shock. Low blood
Oliguria X pressure, a rapid and weak pulse, decreased urine
Restlessness X output, and signs of decreased blood flow to the brain,
such as confusion and restlessness, are all common
Blood pressure 85/69 mmHg X
symptoms of cardiogenic shock. Cardiogenic shock is a
Temp 37 C X
potentially fatal complication of MI, with a mortality
Decreased urine output X rate approaching 90%. Fever is not a common symptom
of cardiogenic shock.

9.) 2. Review antihypertensive medication. 2. Blood pressure and heart rate.

-To determine the cause of orthostatic -To monitor for progression or
2. Orthostatic hypotension
hypotension, if it is iatrogenic. improvement of orthostatic hypotension.
-There is a significant drop of
3. Counsel on physical activity modification
BP from supine to standing
such as rising slowly and avoiding crossing position.
5. Diet and lifestyle.
of legs.
-Crossing of legs and getting up quickly -Modification can lead to progression or
contributes to orthostatic hypotension. improvement of orthostatic hypotension.

10.) 2. Provide chemo education. 3. Molecular genetics.

-IBC treatment modalities include: -Monitor for germline mutations in cancer and
neo/adjuvant chemo/surgery/radiation
therapy/immunotherapy. Depending on
2. Inflammatory breast cancer. also determine targeted therapy.
ER/PR/HER2 status, client may beneft from -Rapid onset of breast pain
hormonal therapy. characterized with lymph node 4. Toxicity check from chemotherapy.
involvement, usually starts as
4. Prepare the client for PET CT. -Monitor iatrogenic effects of chemotherapy.
ductal invasive then it
-For cancer re-staging. progresses to dermal invasion.

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 Practice Exam

Answer Key

11.) child verbalizes that he cannot play with his toys when he gets discharged. , child’s bedroom is on the
second floor. , sister offers help in assisting him climbing the stairs at least twice daily.
Rationale: It is important to let the child do all age-appropriate activities at home that will improve his mobility. The bed of the child with a hip spica
cast who is going home and whose room is on the second floor needs to be moved to a place where the family can spend more time together. A
child in a hip spica cast would find it hard and probably dangerous to go up and down a flight of stairs at least twice a day, when they wake up in
the morning and before they go to bed at night. Since the family is involved in the discharge, the sister should also be taught how to take care of
the child.

12.) moving his upper extremities gently as the mother assisted. , mother demonstrates passive exercises
"I think I will see the physical therapist monthly”.
Rationale: The most important part of the child's care plan is physical therapy. Most cases of torticollis get better when the parents do gentle
stretching exercises every day. The child needs regular physical therapy so that the progress can be tracked. Surgery is only done after several
months of physical therapy and if it is not effective.

13.) hyperventilation, fast and pounding heartbeat, dry mouth , itchiness over his skin. He is anxious and
feeling restless.
Rationale: Clonidine is used alone or together with other medicines to treat hypertension. High blood pressure adds to the workload of the heart and
arteries. If it continues for a long time, the heart and arteries may not function properly. This can damage the blood vessels of the brain, heart,
and kidneys, resulting in a stroke, heart failure, or kidney failure. High blood pressure may also increase the risk for heart attacks. These problems
may be less likely to occur if the blood pressure is controlled. Clonidine (catapres) is a central acting adrenergic antagonist. It reduces sympathetic
outflow from the central nervous system. Dry mouth, impotence, and sleep disturbances are possible adverse effects.

14.) persistent headache that’s worse in the morning , acts lethargic, or extra sleepy, for no apparent reason.
tilting her head, lethargic, and suddenly vomits.
Rationale: The signs and symptoms of a child with a brain tumor is worsening headache, head tilting, nausea and vomiting, and lethargy are hallmark
signs during assessment. Clinical manifestations are the result of location and size of the tumor. Increase in appetite is a result of growth spurt
can cause a person to eat more, and it is not always a sign of a brain tumor.

15.) ☒1. Administration of hepatitis b immune globulin at birth.

☒2. Follow the series of three (3) hepatitis b vaccinations as scheduled.
☒5. Maintain universal precautions for both mother and the newborn.
Rationale: The mother has active hepatitis and is a carrier, according to the test results. Hepatitis b immune globulin given at birth protects against
hepatitis b passively and acts as a preventive treatment. Also, the newborn needs to get the first of three shots of the vaccine. Since the baby
already has hepatitis b, he should not be screened or put in a separate room. As with all clients, universal precautions should be taken, which are
enough to stop the spread of viruses. Women who have a positive test for hepatitis b surface antigen can still breastfeed.

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 Practice Exam

Answer Key

16.) ☒1. Ambulate in the labor room.

☒2. Have the client do slow chest breathing.
☒4. Massage her abdomen lightly.
Rationale: During the first stage of labor, most of the pain comes from the lower part of the uterus stretching, the cervix and perineum opening up,
pressure on nearby structures, and lack of oxygen to the uterine and cervical muscle cells during contractions. Walking will help the muscles relax and
get more blood to the area. Slow chest breathing can help a woman in the early stages of labor get more oxygen and feel calmer. While the woman
or her coach is taking slow chest breaths, the abdomen can be gently massaged (effleurage). The uterine muscles get more oxygen and relax when
you breathe into your chest and massage them. Since most pain medications slow down labor, they are not used in the first stage. Anesthesia may be
used in the second stage. Even though drinking ice water can help you stay hydrated, it will not help address pain.

17.) ☒1. One milkshake or yogurt with fresh fruit or one granola bar.
☒3. Cheese pizza with spinach and pepperoni topping.
☒4. Peanut butter with crackers and a juice drink.
Rationale: Fresh fruits and vegetables, dairy products, protein-rich foods (such as cheese and peanut butter), and fruits and vegetables are all great
options. Fried foods, such tater tots and chicken nuggets, as well as foods like cheeseburgers and buttered popcorn, are rich in fat; carbonated
beverages, including diet colas, as well as foods like pickles and ketchup, are high in sodium. These meals can cause ankle edema and encourage weight
gain by providing empty calories.

18.) ☒1. Headache

☒2. +2 edema of the ankles and feet
☒3. Protein:++ in urinalysis
☒4. BP 150/96 mmHg
☒6. Stomach pain
Rationale: Protein in the urine and a blood pressure increase of 140/90 mmHg or more are the main signs of preeclampsia. Since the client's blood
pressure meets the criteria for gestational hypertension, the next step for the nurse is to find out if she has protein in her urine. If not, she might
be having momentary high blood pressure. The person with preeclampsia will have very swollen hands and face. Even though headaches can be caused
by many different things, they are a major cause of high blood pressure during pregnancy. The client's blood glucose level has nothing to do with a
diagnosis of preeclampsia.

19.) The client is likely having: Pulmonary embolism persistent with findings : Chest pain, dyspnea and swelling of
calves.
Rationale: Pulmonary embolism happens when there is a blood clot formation resulting from prolonged immobilization or blood disorders. This can be
manifested by chest pain, shortness of breath, swelling of legs, crackles ,wheezing, cough, distended neck veins or hypotension.

20.) The client is likely having Gastroesophageal reflux disease which can be best controlled with esomeprazole.
Rationale: GERD is a disorder that occurs when stomach contents reflux creates bothersome symptoms or complications. GERD affects 20% of
individuals, with at least weekly occurrences of heartburn reported, and up to 10% reporting daily symptoms. Although the majority of clients have
moderate symptoms, up to one-third have esophageal mucosal injury (reflux esophagitis), and a few develop more significant problems.
To minimize acid production and facilitate healing, this client should be given a proton pump inhibitor (PPI). Although an H2 receptor antagonist may be
beneficial, PPIs are recommended. An antacid would reduce stomach acid, but its effects would be short-lived in comparison to PPIs and H2 receptor
inhibitors.
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 CONGESTIVE HEART FAILURE
CASE STUDY

Answer Key
QUESTION #1
Among all the signs and symptoms manifested by the client, identify which 3 assessment findings is
mostly expected. Rationale: Most clients with congestive heart failure signs and symptoms may include:
Select N that apply. shortness of breath with activity or when lying down, fatigue and weakness, swelling in
the legs, ankles and feet. Heart failure doesn't mean the heart has stopped working.
☒ Dyspnea
rather, it means that the heart works less efficiently than normal. Due to various
☒ Fatigue possible causes, blood moves through the heart and body at a slower rate, and pressure
☒ Bilateral pedal edema +2 in the heart increases, but heart failure can occur even with a normal ejection fraction.
This happens if the heart muscle becomes stiff from conditions such as high blood
pressure.

QUESTION #2
For each assessment check to classify if the finding is HELPFUL or NOT HELPFUL in diagnosing CHF in
client.
Rationale: Diagnosis of congestive heart failure is achieved
Diagnostic / Laboratory results Helpful Not Helpful
through a comprehensive assessment of the heart muscle,
Brain natriuretic peptide (BPN) level 450 pg/mL ☒ ☐ including evaluation of its pumping action and thickness of
CK-MB 10 IU/L ☐ ☒ its walls. This testing also helps to determine the
underlying cause of heart failure. Diagnostic tests for
Echocardiogram – Systolic dysfunction ☒ ☐ congestive heart failure may include: ECG,
Troponin I 0ng/mL ☐ ☒ Echocardiogram, CT scan, BPN (brain natriuretic peptide)
Na 140 mmol/L ☐ ☒ level.
ECG – abnormal findings ☒ ☐
K 5.0 mmol/L ☐ ☒

QUESTION #3
Relate one condition and two assessment to fill in each blank of the following sentence.
The client is at highest risk for Decreased cardiac output as evidenced by the
condition
client's Dyspnea and BP 165/100 mmHg
assessment 1 assessment 2

Rationale: The heart fails to pump enough blood to meet the metabolic needs
of the body. The blood flow that supplies the heart is also decreased;
therefore, decrease in cardiac output occurs. Blood then is insufficient and
making it difficult to circulate the blood to all parts of the body, thus may
cause changes in BP (hypotension/hypertension), increased heart rate
(tachycardia), dysrhythmias, ECG change, dyspnea, extra heart sounds (S3, S 4),
decreased urine output (oliguria). ReMarNurse.com
 CONGESTIVE HEART FAILURE
CASE STUDY

Answer Key
QUESTION #4
Check the anticipated provider orders from each of the following categories:
Each category have 2 potential orders.

Categories Anticipated Orders Rationale: While sodium helps keep

Diet ☒Low sodium diet a normal balance of fluid in your
☐High protein diet body, those living with heart failure
need to follow a low-sodium diet
☒High fiber diet
because it helps control symptoms
Activity / Restrictions ☒Avoid strenuous activity and can prevent other heart
☐Complete bed rest with bathroom privileges problems.
☒Aerobic activity with rest periods High-fiber foods may have other
heart-health benefits, such as
Monitoring ☒Blood pressure reducing blood pressure and
☐Oxygen saturation inflammation.
☒Pulse rate

QUESTION #5
For each possible intervention check to evaluate if the intervention is ESSENTIAL or
CONTRAINDICATED.
Rationale: Vasodilators are an important adjunct to the inpatient
Possible interventions Essential Contraindicated treatment of CHF. They work mainly by reducing the afterload
☐ on the myocardium although preload reduction also occurs.
IV fluids ☒
Effective diuretic therapy provides impressive symptomatic
Diuretics ☒ ☐ relief in clients with CHF. Hemodynamically, forced diuresis
results in a decrease in pulmonary circulation wedge pressure,
NSAIDs ☐ ☒ and stroke volume and cardiac output decrease initially. Cardiac
Vasodilators ☒ ☐ glycosides are medicines for treating heart failure and certain
irregular heartbeats. They are one of several classes of drugs
Cardiac glycosides ☒ ☐ used to treat the heart and related conditions.

The administration of IV fluids may worsen the congestive symptoms. Researchers decided to investigate the use of IV fluids in clients with
heart failure. Many clients hospitalized with severe heart failure are receiving potentially harmful treatment with intravenous fluids. Existing CHF
may worsen after use of NSAIDs by inhibition of diuretic therapy and by adverse renal effects, especially in elderly clients with renal
impairment and cardiovascular comorbidity.

ReMarNurse.com
 CONGESTIVE HEART FAILURE
CASE STUDY

Answer Key
QUESTION #6

Highlight the findings that indicate the client is ready for discharge.

Nurses notes:

The client’s vital signs has been constantly within normal range, also the client did not report further episodes of
dyspnea. The client stated that he was able to sleep at least 7 hours per night and that he has regained his
appetite. The client also stated that he is learning to watch for changes in his heart rate, blood pressure and
weight. Also, he agreed to limit his sodium intake to improve his condition.
Rationale: Client with improved condition may demonstrate adequate cardiac output as evidenced by vital signs within acceptable limits, dysrhythmias
absent/controlled, and no symptoms of failure (e.g., hemodynamic parameters within acceptable limits, urinary output adequate). Also, the client will
report decreased or no episodes of dyspnea. You will need to learn to watch for changes in your heart rate, pulse, blood pressure, and weight.
You will also need to limit salt in your diet, stop drinking alcohol, quit smoking, exercise, lose weight, if you need to, and get enough rest. You will need
to eat less salt. Salt can make you thirsty and being thirsty can cause you to drink too much fluid. Extra salt also makes fluid stay in your body.

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