Bundle
Bundle for Saunders NCLEX exam upgraded /verified
10 Items
Saunders NCLEX Cardiovascular correctly answered
A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for cardiac catheterization. Which medication woul... [Show More] d need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? 1. Glipizide 2. Metformin 3. Repaglinide 4. Regular insulin Metformin Metformin needs to be withheld 24 hours before and for 48 hours after cardiac catheterization because of the injection of contrast medium during the procedure. If the contrast medium affects kidney function, with metformin in the system the client would be at increased risk for lactic acidosis. The medications in the remaining options do not need to be withheld 24 hours before and 48 hours after cardiac catheterization. A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem? 1. Hypovolemia 2. Acute kidney injury 3. Glomerulonephritis 4. Urinary tract infection Acute kidney injury The client who undergoes cardiac surgery is at risk for renal injury from poor perfusion, hemolysis, low cardiac output, or vasopressor medication therapy. Renal injury is signaled by decreased urine output and increased blood urea nitrogen (BUN) and creatinine levels. Normal reference levels are BUN, 10-20 mg/dL (3.6-7.1 mmol/L), and creatinine, male, 0.6-1.2 mg/dL (53-106 mcmol/L) and female 0.5-1.1 mg/dL (44-97 mcmol/L). The client may need medications to increase renal perfusion and possibly could need peritoneal dialysis or hemodialysis. No data in the question indicate the presence of hypovolemia, glomerulonephritis, or urinary tract infection. The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats/minute. Which action should the nurse take? 1. Check vital signs. 2. Check laboratory test results. 3. Notify the health care provider. 4. Continue to monitor for any rhythm change. Continue to monitor for any rhythm change. Normal sinus rhythm is defined as a regular rhythm, with an overall rate of 60 to 100 beats/minute. The PR and QRS measurements are normal, measuring between 0.12 and 0.20 seconds and 0.04 and 0.10 seconds, respectively. There are no irregularities in this rhythm currently, so there is no immediate need to check vital signs or laboratory results, or to notify the health care provider. Therefore, the nurse would continue to monitor the client for any rhythm change. A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? 1. Call a code. 2. Call the health care provider. 3. Check the client's status and lead placement. 4. Press the recorder button on the electrocardiogram console. Check the client's status and lead placement. Sudden loss of electrocardiographic complexes indicates ventricular asystole or possibly electrode displacement. Accurate assessment of the client and equipment is necessary to determine the cause and identify the appropriate intervention. The remaining options are secondary to client assessment. The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority? 1. Blood pressure 2. Status of airway 3. Oxygen flow rate 4. Level of consciousness Status of airway Nursing responsibilities after cardioversion include maintenance first of a patent airway, and then oxygen administration, assessment of vital signs and level of consciousness, and dysrhythmia detection. The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse should assess which item based on priority? 1. Anxiety level of the client and family 2. Presence of a MedicAlert card for the client to carry 3. Knowledge of restrictions on postdischarge physical activity 4. Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver The nurse who is caring for the client after insertion of an automatic internal cardioverter-defibrillator needs to assess device settings, similar to after insertion of a permanent pacemaker. Specifically, the nurse needs to know whether the device is activated, the heart rate cutoff above which it will fire, and the number of shocks it is programmed to deliver. The remaining options are also nursing interventions but are not the priority. A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How should the nurse correctly interpret this rhythm? 1. Sinus tachycardia 2. Sinus bradycardia 3. Sinus dysrhythmia 4. Normal sinus rhythm Sinus tachycardia Sinus tachycardia has the characteristics of normal sinus rhythm, including a regular PP interval and normal-width PR and QRS intervals; however, the rate is the differentiating factor. In sinus tachycardia, the atrial and ventricular rates are greater than 100 beats/minute. The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status? 1. The neurovascular status is normal because of increased blood flow through the leg. 2. The neurovascular status is moderately impaired, and the surgeon should be called. 3. The neurovascular status is slightly deteriorating and should be monitored for another hour. 4. The neurovascular status is adequate from an arterial approach, but venous complications are arising. The neurovascular status is normal because of increased blood flow through the leg. An expected outcome of aortoiliac bypass graft surgery is warmth, redness, and edema in the surgical extremity because of increased blood flow. The remaining options are incorrect interpretations. The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective? 1. Muffled heart sounds 2. A rise in blood pressure 3. Jugular venous distention 4. Client expressions of dyspnea A rise in blood pressure Following pericardiocentesis, the client usually expresses immediate relief. Heart sounds are no longer muffled or distant and blood pressure increases. Distended neck veins are a sign of increased venous pressure, which occurs with cardiac tamponade. A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching? 1. "I should notify my doctor if my feet or legs start to swell." 2. "My doctor told me to call his office if my pulse rate decreases below 60." 3. "Avoiding grapefruit juice will definitely be a challenge for me, since I usually drink it every morning with breakfast." 4. "My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning." "My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning." Variant angina, or Prinzmetal's angina, is prolonged and severe and occurs at the same time each day, most often at rest. The pain is a result of coronary artery spasm. The treatment of choice is usually a calcium channel blocker, which relaxes and dilates the vascular smooth muscle, thus relieving the coronary artery spasm in variant angina. Adverse effects can include peripheral edema, hypotension, bradycardia, and heart failure. Grapefruit juice interacts with calcium channel blockers and should be avoided. If bradycardia occurs, the client should contact the health care provider. Clients should also be taught to change positions slowly to prevent orthostatic hypotension. Physical exertion does not cause this type of angina; therefore, the client should be able to continue morning walks with his or her spouse. The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding indicates the presence of this complication? 1. Flat neck veins 2. A pulse rate of 60 beats/minute 3. Muffled or distant heart sounds 4. Wheezing on auscultation of the lungs Muffled or distant heart sounds Assessment findings associated with cardiac tamponade include tachycardia, distant or muffled heart sounds, jugular vein distention with clear lung sounds, and a falling blood pressure accompanied by pulsus paradoxus (a drop in inspiratory blood pressure greater than 10 mm Hg). The other options are not signs of cardiac tamponade. The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction? 1. "I need to be sure not to go barefoot around the house." 2. "If I cut my toenails, I need to be sure that I cut them straight across." 3. "It is all right to apply lanolin to my feet, but I shouldn't place it between my toes." 4. "I need to be sure that I elevate my leg above the level of my heart for at least an hour every day." "I need to be sure that I elevate my leg above the level of my heart for at least an hour every day." Foot care instructions for the client with peripheral arterial disease are the same as those for a client with diabetes mellitus. The client with arterial disease, however, should avoid raising the legs above the level of the heart unless instructed to do so as part of an exercise program or if venous stasis is also present. The client statements in the remaining options are correct statements, and indicate that the teaching has been effective. The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to be avoided. The nurse instructs the client to avoid consuming which item? 1. Bananas 2. Broccoli 3. Antacids 4. Cantaloupe Antacids The sodium level can increase with the use of several types of products, including toothpaste and mouthwash; over-the-counter medications such as analgesics, antacids, laxatives, and sedatives; and softened water and mineral water. Clients are instructed to read labels for sodium content. Water that is bottled, distilled, deionized, or demineralized may be used for drinking and cooking. Fresh fruits and vegetables are low in sodium. The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse should plan to provide which instruction to the client? 1. Use nail polish to protect the nail beds from injury. 2. Wear gloves for all activities involving the use of both hands. 3. Stop smoking because it causes cutaneous blood vessel spasm. 4. Always wear warm clothing, even in warm climates, to prevent vasoconstriction. Stop smoking because it causes cutaneous blood vessel spasm. Raynaud's disease is peripheral vascular disease characterized by abnormal vasoconstriction in the extremities. Smoking cessation is one of the most important lifestyle changes that the client must make. The nurse should emphasize the effects of tobacco on the blood vessels and the principles involved in stopping smoking. The nurse needs to provide information to the client about smoking cessation programs available in the community. It is not necessary to wear gloves for all activities, nor should warm clothing be worn in warm climates. The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. Which is a priority intervention? 1. Keep the legs aligned with the heart. 2. Elevate the legs higher than the heart. 3. Clean the skin with alcohol every hour. 4. Position the client onto the side during every shift. Elevate the legs higher than the heart. In the client with a venous disorder, the legs are elevated above the level of the heart to assist with the return of venous blood to the heart. Alcohol is very irritating and drying to tissues and should not be used in areas of skin breakdown. Option 4 specifies infrequent care intervals, so it is not the priority intervention. The nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit (ICU). The nurse notes that a cardiac troponin T assay was performed while the client was in the ICU. The nurse determines that this test was performed to assist in diagnosing which condition? 1. Heart failure 2. Atrial fibrillation 3. Myocardial infarction 4. Ventricular tachycardia Myocardial infarction [Show Less]
- Exam
- $20.45
- 0
- 139
Saunders NCLEX-RN question and correct answers 2022
Saunders NCLEX-RN question and correct answers 2022
- Exam
- $21.45
- 0
- 193
Saunders NCLEX Endocrine correctly answered graded A+ to pass
A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would i... [Show More] mmediately prepare to initiate which anticipated health care provider's prescription? 1. Endotracheal intubation 2. 100 units of NPH insulin 3. Intravenous infusion of normal saline 4. Intravenous infusion of sodium bicarbonate Intravenous infusion of normal saline The primary goal of treatment in hyperosmolar hyperglycemic syndrome (HHS) is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. Intravenous (IV) fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline. Regular insulin, not NPH insulin, would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium levels. Intubation and mechanical ventilation are not required to treat HHS. An external insulin pump is prescribed for a client with diabetes mellitus. When the client asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump? 1. It is timed to release programmed doses of either short-duration or NPH insulin into the bloodstream at specific intervals. 2. It continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels. 3. It is surgically attached to the pancreas and infuses regular insulin into the pancreas. This releases insulin into the bloodstream. 4. It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal. It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal. An insulin pump provides a small continuous dose of short-duration (rapid- or short-acting) insulin subcutaneously throughout the day and night. The client can self-administer an additional bolus dose from the pump before each meal as needed. Short-duration insulin is used in an insulin pump. An external pump is not attached surgically to the pancreas. A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings support this diagnosis? Select all that apply. 1. Increase in pH 2. Comatose state 3. Deep, rapid breathing 4. Decreased urine output 5. Elevated blood glucose level 2. Comatose state 3. Deep, rapid breathing 5. Elevated blood glucose level Because of the profound deficiency of insulin associated with DKA, glucose cannot be used for energy and the body breaks down fat as a secondary source of energy. Ketones, which are acid byproducts of fat metabolism, build up and the client experiences a metabolic ketoacidosis. High serum glucose contributes to an osmotic diuresis and the client becomes severely dehydrated. If untreated, the client will become comatose due to severe dehydration, acidosis, and electrolyte imbalance. Kussmaul's respirations, the deep rapid breathing associated with DKA, is a compensatory mechanism by the body. The body attempts to correct the acidotic state by blowing off carbon dioxide (CO2), which is an acid. In the absence of insulin, the client will experience severe hyperglycemia. Option 1 is incorrect because in acidosis the pH would be low. Option 4 is incorrect because a high serum glucose will result in an osmotic diuresis and the client will experience polyuria. The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptom or symptoms develop? Select all that apply. 1. Polyuria 2. Shakiness 3. Palpitations 4. Blurred vision 5. Lightheadedness 6. Fruity breath odor 2. Shakiness 3. Palpitations 5. Lightheadedness Shakiness, palpitations, and lightheadedness are signs/symptoms of hypoglycemia and would indicate the need for food or glucose. Polyuria, blurred vision, and a fruity breath odor are manifestations of hyperglycemia. A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. What is the appropriate intervention to decrease the client's anxiety? 1. Administer a sedative. 2. Convey empathy, trust, and respect toward the client. 3. Ignore the signs and symptoms of anxiety, anticipating that they will soon disappear. 4. Make sure that the client is familiar with the correct medical terms to promote understanding of what is happening. Convey empathy, trust, and respect toward the client. Anxiety is a subjective feeling of apprehension, uneasiness, or dread. The appropriate intervention is to address the client's feelings related to the anxiety. Administering a sedative is not the most appropriate intervention and does not address the source of the client's anxiety. The nurse should not ignore the client's anxious feelings. Anxiety needs to be managed before meaningful client education can occur. The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement? 1. "I will stop taking my insulin if I'm too sick to eat." 2. "I will decrease my insulin dose during times of illness." 3. "I will adjust my insulin dose according to the level of glucose in my urine." 4. "I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL (14.2 mmol/L)." "I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL (14.2 mmol/L)." During illness, the client with type 1 diabetes mellitus is at increased risk of diabetic ketoacidosis, due to hyperglycemia associated with the stress response and due to a typically decreased caloric intake. As part of sick day management, the client with diabetes should monitor blood glucose levels and should notify the HCP if the level is higher than 250 mg/dL (14.2 mmol/L). Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be adjusted without the HCP's advice and are usually adjusted on the basis of blood glucose levels, not urinary glucose readings. A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dL (54.2 mmol/L). A continuous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.7 mmol/L). The nurse would next prepare to administer which medication? 1. An ampule of 50% dextrose 2. NPH insulin subcutaneously 3. IV fluids containing dextrose 4. Phenytoin for the prevention of seizures IV fluids containing dextrose Emergency management of DKA focuses on correcting fluid and electrolyte imbalances and normalizing the serum glucose level. If the corrections occur too quickly, serious consequences, including hypoglycemia and cerebral edema, can occur. During management of DKA, when the blood glucose level falls to 250 to 300 mg/dL (14.2 to 17.1 mmol/L), the IV infusion rate is reduced and a dextrose solution is added to maintain a blood glucose level of about 250 mg/dL (14.2 mmol/L), or until the client recovers from ketosis. Fifty percent dextrose is used to treat hypoglycemia. NPH insulin is not used to treat DKA. Phenytoin is not a usual treatment measure for DKA. The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign or symptom, if exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed? 1. Polyuria 2. Diaphoresis 3. Pedal edema 4. Decreased respiratory rate Polyuria Chronic hyperglycemia, resulting from poor glycemic control, contributes to the microvascular and macrovascular complications of diabetes mellitus. Classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Diaphoresis may occur in hypoglycemia. Hypoglycemia is an acute complication of diabetes mellitus; however, it does not predispose a client to the chronic complications of diabetes mellitus. Therefore, option 2 can be eliminated because this finding is characteristic of hypoglycemia. Options 3 and 4 are not associated with diabetes mellitus. The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places priority on which client problem? 1. Lack of knowledge 2. Inadequate fluid volume 3. Compromised family coping 4. Inadequate consumption of nutrients Inadequate fluid volume An increased blood glucose level will cause the kidneys to excrete the glucose in the urine. This glucose is accompanied by fluids and electrolytes, causing an osmotic diuresis leading to dehydration. This fluid loss must be replaced when it becomes severe. Options 1, 3, and 4 are not related specifically to the information in the question. The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching? 1. "I need to stop my insulin." 2. "I need to increase my fluid intake." 3. "I need to monitor my blood glucose every 3 to 4 hours." 4. "I need to call the health care provider (HCP) because of these symptoms." "I need to stop my insulin." When a client with diabetes mellitus is unable to eat normally because of illness, the client still should take the prescribed insulin or oral medication. The client should consume additional fluids and should notify the HCP. The client should monitor the blood glucose level every 3 to 4 hours. The client should also monitor the urine for ketones during illness. The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action? 1. Lower the head of the bed. 2. Test the drainage for glucose. 3. Obtain a culture of the drainage. 4. Continue to observe the drainage. Test the drainage for glucose. After hypophysectomy, the client should be monitored for rhinorrhea, which could indicate a cerebrospinal fluid leak. If this occurs, the drainage should be collected and tested for the presence of cerebrospinal fluid. Cerebrospinal fluid contains glucose, and if positive, this would indicate that the drainage is cerebrospinal fluid. The head of the bed should remain elevated to prevent increased intracranial pressure. Clear nasal drainage would not indicate the need for a culture. Continuing to observe the drainage without taking action could result in a serious complication. The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118 mmol/L). Which health care provider prescriptions should the nurse anticipate receiving? Select all that apply. 1. Initiate an infusion of 3% NaCl. 2. Administer intravenous furosemide. 3. Restrict fluids to 800 mL over 24 hours. 4. Elevate the head of the bed to high Fowler's. 5. Administer a vasopressin antagonist as prescribed. 1. Initiate an infusion of 3% NaCl. 3. Restrict fluids to 800 mL over 24 hours. 5. Administer a vasopressin antagonist as prescribed Clients with SIADH experience excess secretion of antidiuretic hormone (ADH), which leads to excess intravascular volume, a declining serum osmolarity, and dilutional hyponatremia. Management is directed at correcting the hyponatremia and preventing cerebral edema. Hypertonic saline is prescribed when the hyponatremia is severe, less than 120 mEq/L (120 mmol/L). An intravenous (IV) infusion of 3% saline is hypertonic. Hypertonic saline must be infused slowly as prescribed and an infusion pump must be used. Fluid restriction is a useful strategy aimed at correcting dilutional hyponatremia. Vasopressin is an ADH; vasopressin antagonists are used to treat SIADH. Furosemide may be used to treat extravascular volume and dilutional hyponatremia in SIADH, but it is only safe to use if the serum sodium is at least 125 mEq/L (125 mmol/L). When furosemide is used, potassium supplementation should also occur and serum potassium levels should be monitored. To promote venous return, the head of the bed should not be raised more than 10 degrees for the client with SIADH. Maximizing venous return helps to avoid stimulating stretch receptors in the heart that signal to the pituitary that more ADH is needed. A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially? 1. Warm the client. 2. Maintain a patent airway. 3. Administer thyroid hormone. 4. Administer fluid replacement. Maintain a patent airway. Myxedema coma is a rare but serious disorder that results from persistently low thyroid production. Coma can be precipitated by acute illness, rapid withdrawal of thyroid medication, anesthesia and surgery, hypothermia, and the use of sedatives and opioid analgesics. In myxedema coma, the initial nursing action is to maintain a patent airway. Oxygen should be administered, followed by fluid replacement, keeping the client warm, monitoring vital signs, and administering thyroid hormones by the intravenous route. The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention? 1. Correct the acidosis. 2. Administer 5% dextrose intravenously. 3. Apply a monitor for an electrocardiogram. 4. Administer short-duration insulin intravenously. Administer short-duration insulin intravenously. Lack of insulin (absolute or relative) is the primary cause of DKA. Treatment consists of insulin administration (short- or rapid-acting), intravenous fluid administration (normal saline initially, not 5% dextrose), and potassium replacement, followed by correcting acidosis. Cardiac monitoring is important due to alterations in potassium levels associated with DKA and its treatment, but applying an electrocardiogram monitor is not the priority action. A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding of the peak action of NPH insulin and exercise? 1. "I should not exercise since I am taking insulin." 2. "The best time for me to exercise is after breakfast." 3. "The best time for me to exercise is mid- to late afternoon." 4. "NPH is a basal insulin, so I should exercise in the evening." "The best time for me to exercise is after breakfast." Exercise is an important part of diabetes management. It promotes weight loss, decreases insulin resistance, and helps to control blood glucose levels. A hypoglycemic reaction may occur in response to increased exercise, so clients should exercise either an hour after mealtime or after consuming a 10- to 15-gram carbohydrate snack, and they should check their blood glucose level before exercising. Option 1 is incorrect because clients with diabetes should exercise, though they should check with their health care provider before starting a new exercise program. Option 3 in incorrect; clients should avoid exercise during the peak time of insulin. NPH insulin peaks at 4 to 12 hours; therefore, afternoon exercise takes place during the peak of the medication. Options 4 is incorrect; NPH insulin in an intermediate-acting insulin, not a basal insulin. The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder? Select all that apply. 1. Polyuria 2. Headache 3. Bone pain 4. Nervousness 5. Weight gain 1. Polyuria 3. Bone pain The role of parathyroid hormone (PTH) in the body is to maintain serum calcium homeostasis. In hyperparathyroidism, PTH levels are high, which causes bone resorption (calcium is pulled from the bones). Hypercalcemia occurs with hyperparathyroidism. Elevated serum calcium levels produce osmotic diuresis and thus polyuria. This diuresis leads to dehydration (weight loss rather than weight gain). Loss of calcium from the bones causes bone pain. Options 2, 4, and 5 are not associated with hyperparathyroidism. Some gastrointestinal symptoms include anorexia, nausea, vomiting, and constipation. The nurse is teaching a client with hyperparathyroidism how to manage the condition at home. Which response by the client indicates the need for additional teaching? 1. "I should limit my fluids to 1 liter per day." 2. "I should use my treadmill or go for walks daily." 3. "I should follow a moderate-calcium, high-fiber diet." 4. "My alendronate helps to keep calcium from coming out of my bones." "I should limit my fluids to 1 liter per day." In hyperparathyroidism, clients experience excess parathyroid hormone (PTH) secretion. A role of PTH in the body is to maintain serum calcium homeostasis. When PTH levels are high, there is excess bone resorption (calcium is pulled from the bones). In clients with elevated serum calcium levels, there is a risk of nephrolithiasis. One to 2 liters of fluids daily should be encouraged to protect the kidneys and decrease the risk of nephrolithiasis. Moderate physical activity, particularly weight-bearing activity, minimizes bone resorption and helps to protect against pathological fracture. Walking, as an exercise, should be encouraged in the client with hyperparathyroidism. Clients should follow a moderate-calcium, high-fiber diet. Even though serum calcium is already high, clients should follow a moderate-calcium diet because a low-calcium diet will surge PTH. Calcium causes constipation, so a diet high in fiber is recommended. Alendronate is a bisphosphate that inhibits bone resorption. In bone resorption, bone is broken down and calcium is deposited into the serum. A client with a diagnosis of Addisonian crisis is being admitted to the intensive care unit. Which findings will the interprofessional health care team focus on? Select all that apply. 1. Hypotension 2. Leukocytosis 3. Hyperkalemia 4. Hypercalcemia 5. Hypernatremia 1. Hypotension 3. Hyperkalemia In Addison's disease, also known as adrenal insufficiency, destruction of the adrenal gland leads to decreased production of adrenocortical hormones, including the glucocorticoid cortisol and the mineralocorticoid aldosterone. Addisonian crisis, also known as acute adrenal insufficiency, occurs when there is extreme physical or emotional stress and lack of sufficient adrenocortical hormones to manage the stressor. Addisonian crisis is a life-threatening emergency. One of the roles of endogenous cortisol is to enhance vascular tone and vascular response to the catecholamines epinephrine and norepinephrine. Hypotension occurs when vascular tone is decreased and blood vessels cannot respond to epinephrine and norepinephrine. The role of aldosterone in the body is to support the blood pressure by holding salt and water and excreting potassium. When there is insufficient aldosterone, salt and water are lost and potassium builds up; this leads to hypotension from decreased vascular volume, hyponatremia, and hyperkalemia. The remaining options are not associated with Addisonian crisis. The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply. 1. Tremors 2. Anorexia 3. Irritability 4. Nervousness 5. Hot, dry skin 6. Muscle cramps 1. Tremors 3. Irritability 4. Nervousness Decreased blood glucose levels produce autonomic nervous system symptoms, which are manifested classically as nervousness, irritability, and tremors. Option 5 is more likely to occur with hyperglycemia. Options 2 and 6 are unrelated to the manifestations of hypoglycemia. In hypoglycemia, usually the client feels hunger. The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder? 1. A urinary output of 50 mL/hour 2. A coagulation time of 5 minutes 3. A heart rate that is 90 beats/minute and irregular 4. A blood urea nitrogen level of 20 mg/dL (7.1 mmol/L) A heart rate that is 90 beats/minute and irregular Pheochromocytoma is a catecholamine-producing tumor usually found in the adrenal medulla, but extraadrenal locations include the chest, bladder, abdomen, and brain; it is typically a benign tumor but can be malignant. Excessive amounts of epinephrine and norepinephrine are secreted. The complications associated with pheochromocytoma include hypertensive retinopathy and nephropathy, myocarditis, increased platelet aggregation, and stroke. Death can occur from shock, stroke, kidney failure, dysrhythmias, or dissecting aortic aneurysm. An irregular heart rate indicates the presence of a dysrhythmia. A coagulation time of 5 minutes is normal. A urinary output of 50 mL/hour is an adequate output. A blood urea nitrogen level of 20 mg/dL (7.1 mmol/L) is a normal finding. The nurse is monitoring a client diagnosed with acromegaly who was treated with transsphenoidal hypophysectomy and is recovering in the intensive care unit. Which findings should alert the nurse to the presence of a possible postoperative complication? Select all that apply. 1. Anxiety 2. Leukocytosis 3. Chvostek's sign 4. Urinary output of 800 mL/hour 5. Clear drainage on nasal dripper pad 2. Leukocytosis 4. Urinary output of 800 mL/hour 5. Clear drainage on nasal dripper pad Acromegaly results from excess secretion of growth hormone, usually caused by a benign tumor on the anterior pituitary gland. Treatment is surgical removal of the tumor, usually with a sublingual transsphenoidal complete or partial hypophysectomy. The sublingual transsphenoidal approach is often through an incision in the inner upper lip at the gum line. Transsphenoidal surgery is a type of brain surgery and infection is a primary concern. Leukocytosis, or an elevated white count, may indicate infection. Diabetes insipidus is a possible complication of transsphenoidal hypophysectomy. In diabetes insipidus there is decreased secretion of antidiuretic hormone and clients excrete large amounts of dilute urine. Following transsphenoidal surgery, the nasal passages are packed and a dripper pad is secured under the nares. Clear drainage on the dripper pad is suggestive of a cerebrospinal fluid leak. The surgeon should be notified and the drainage should be tested for glucose. A cerebrospinal fluid leak increases the postoperative risk of meningitis. Anxiety is a nonspecific finding that is common to many disorders. Chvostek's sign is a test of nerve hyperexcitability associated with hypocalcemia and is seen as grimacing in response to tapping on the facial nerve. Chvostek's sign has no association with complications of sublingual transsphenoidal hypophysectomy. The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 120 mg/dL (6.8 mmol/L), temperature of 101°F (38.3°C), pulse of 102 beats/minute, respirations of 22 breaths/minute, and blood pressure of 142/72 mm Hg. Which finding would be the priority concern to the nurse? 1. Pulse 2. Respiration 3. Temperature 4. Blood pressure Temperature In the client with type 2 diabetes mellitus, an elevated temperature may indicate infection. Infection is a leading cause of hyperosmolar hyperglycemic syndrome in the client with type 2 diabetes mellitus. The other findings are within normal limits. The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply. 1. Tremors 2. Weight loss 3. Feeling cold 4. Loss of body hair 5. Persistent lethargy 6. Puffiness of the face 3. Feeling cold 4. Loss of body hair 5. Persistent lethargy 6. Puffiness of the face Feeling cold, hair loss, lethargy, and facial puffiness are signs of hypothyroidism. Tremors and weight loss are signs of hyperthyroidism. A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client? 1. Hypoglycemia 2. Level of hoarseness 3. Respiratory distress 4. Edema at the surgical site Respiratory distress Thyroidectomy is the removal of the thyroid gland, which is located in the anterior neck. It is very important to monitor airway status, as any swelling to the surgical site could cause respiratory distress. Although all of the options are important for the nurse to monitor, the priority nursing action is to monitor the airway. A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder? Select all that apply. 1. Fever 2. Nausea 3. Lethargy 4. Tremors 5. Confusion 6. Bradycardia 1. Fever 2. Nausea 4. Tremors 5. Confusion Thyroid storm is an acute and life-threatening complication that occurs in a client with uncontrollable hyperthyroidism. Signs and symptoms of thyroid storm include elevated temperature (fever), nausea, and tremors. In addition, as the condition progresses, the client becomes confused. The client is restless and anxious and experiences tachycardia. The nurse is caring for a client scheduled for a transsphenoidal hypophysectomy. The preoperative teaching instructions should include which statement? 1. "Your hair will need to be shaved." 2. "You will receive spinal anesthesia." 3. "You will need to ambulate after surgery." 4. "Brushing your teeth needs to be avoided for at least 2 weeks after surgery." "Brushing your teeth needs to be avoided for at least 2 weeks after surgery." A transsphenoidal hypophysectomy is a surgical approach that uses the nasal sinuses and nose for access to the pituitary gland. Based on the location of the surgical procedure, spinal anesthesia would not be used. In addition, the hair would not be shaved. Although ambulating is important, specific to this procedure is avoiding brushing the teeth to prevent disruption of the surgical site. The nurse should include which interventions in the plan of care for a client with hypothyroidism? Select all that apply. 1. Provide a cool environment for the client. 2. Instruct the client to consume a high-fat diet. 3. Instruct the client about thyroid replacement therapy. 4. Encourage the client to consume fluids and high-fiber foods in the diet. 5. Inform the client that iodine preparations will be prescribed to treat the disorder. 6. Instruct the client to contact the health care provider (HCP) if episodes of chest pain occur. 3. Instruct the client about thyroid replacement therapy. 4. Encourage the client to consume fluids and high-fiber foods in the diet. 6. Instruct the client to contact the health care provider (HCP) if episodes of chest pain occur. The clinical manifestations of hypothyroidism are the result of decreased metabolism from low levels of thyroid hormone. Interventions are aimed at replacement of the hormone and providing measures to support the signs and symptoms related to decreased metabolism. The client often has cold intolerance and requires a warm environment. The nurse encourages the client to consume a well-balanced diet that is low in fat for weight reduction and high in fluids and high-fiber foods to prevent constipation. Iodine preparations may be used to treat hyperthyroidism. Iodine preparations decrease blood flow through the thyroid gland and reduce the production and release of thyroid hormone; they are not used to treat hypothyroidism. The client is instructed to notify the HCP if chest pain occurs because it could be an indication of overreplacement of thyroid hormone. A client with Cushing's syndrome verbalizes concern to the nurse regarding the appearance of the buffalo hump that has developed. Which statement should the nurse make to the client? 1. "Don't be concerned; this problem can be covered with clothing." 2. "Usually these physical changes slowly improve following treatment." 3. "This is permanent, but looks are deceiving and are not that important." 4. "Try not to worry about it; there are other things to be concerned about." "Usually these physical changes slowly improve following treatment." The client with Cushing's syndrome should be reassured that most physical changes resolve with treatment. All other options are not therapeutic responses. [Show Less]
- Exam
- $21.45
- 0
- 175
Saunders NCLEX SAFETY with correct answers 100%
The nurse is assisting with planning care for a client with an internal radiation implant. Which should be included in the plan of care? Select all that ap... [Show More] ply. 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 The nurse is planning to begin a continuous tube feeding on a client with a nasogastric (NG) tube. Which interventions should the nurse perform before initiating the feeding? Select all that apply. Explain the procedure to the client. Irrigate the NG tube with saline. Elevate the head of the bed to 45 degrees. The nurse admits a client who has seizure precautions prescribed. The client has a seizure just after the nurse has implemented the precautions. Which actions should the nurse take? Select all that apply. Time the start and stop of the seizure. Apply oxygen at 2L with nasal cannula. Turn the client to the side and do not restrain. Note the distinguishing characteristics of the seizure. Turn on the suction machine with oral catheter. The nurse is preparing to reposition a dependent client who weighs more than 250 lbs. Which interventions should the nurse use to move this client? Select all that apply. Use a friction-reducing slide sheet. Use a mechanical lift to move the client. Keep elbows close and work close to the body. Obtain assistance of a second caregiver to assist with mechanical aids. A licensed practical nurse (LPN) asks an unlicensed assistive personnel (UAP) to gather supplies in preparation for administering a tepid bath to a child with an elevated temperature. The LPN intervenes if the UAP obtains which unnecessary item(s)? A bottle of alcohol A client is having trouble remembering his prescribed medication regimen. Which statement by the nurse is therapeutic? "Let me go over your prescribed medications with you again." The nurse is inquiring about the client's use of complementary and alternative medicines (CAMs). The nurse should be most concerned with the client who uses which CAMs? Select all that apply. Homeopathy Herbal supplements The nurse is caring for a client who underwent a spinal fusion with a metal implant. The nurse notes that the back dressing is wet with clear drainage. Which actions should the nurse take? Select all that apply. Place the client flat in bed. Notify the registered nurse of the drainage. A client is receiving enteral feedings via a gastrostomy tube (G-tube). Which nursing measures are necessary when caring for this client? Select all that apply. Monitoring the skin around the stoma site for skin irritation Administering intermittent feeding through a 60-mL syringe with the plunger removed and the barrel attached to the gastrostomy tube The nurse is caring for a hospitalized older client who has pulled out his IV for the second time. The nurse inserts a new IV. Which intervention should the nurse institute next for the client? Wrap a light roll of gauze to cover the IV site. The nurse enters a client's room and finds that the wastebasket is on fire. The nurse quickly assists the client out of the room. Which is the next nursing action? Activate the fire alarm The nurse is caring for a client who has been prescribed cold pack applications to the right lower extremity. The nurse plans to collect which data specifically associated with this therapy before the initiation of therapy? Select all that apply. Pedal pulses Capillary refill Color of the extremity Temperature of the skin Presence of numbness The nurse is preparing to get a client with tetraplegia (quadriplegia) out of bed into a chair. The nurse places which item on the seat of the chair as the best device for pressure relief? Alternating air pad The nurse is reinforcing instructions provided to a client with a continuous passive motion (CPM) machine. The nurse determines that there is a need for further teaching when the client states that he should perform which action? Reset the degrees of flexion or extension according to comfort. The nurse is teaching the paraplegic client measures to promote skin integrity. Which instructions would be helpful to the client? Select all that apply. Eat a nutritious diet with adequate protein. Use a pressure relief pad while in a wheelchair. Check the bottom sheet for wetness and wrinkles. The nurse is caring for a client with pneumonia who is to receive oxygen via nasal cannula at 2L. To provide a safe delivery of the oxygen the nurse should avoid which actions? Select all that apply. Securing the oxygen tubing to the client's bottom sheet Positioning the nasal prongs in the nares and adjusting the plastic slide on the cannula so that the cannula fits as tight as possible The nurse is caring for an older client who had surgery to repair a fractured hip. In the late evening the client becomes slightly confused and is moving about in bed. Which actions should the nurse take initially? Select all that apply. Ask the client about needing to void or move bowels. Turn on the nightlight in the hospital room and bathroom. Turn on bed alarm The nurse is monitoring the laboratory results of a female client receiving an antineoplastic medication by the intravenous (IV) route. The nurse plans to initiate bleeding precautions if which laboratory result is noted? A platelet count of 40,000 mm3 (40 × 109/L) Which client is the safest one for a licensed practical nurse (LPN) to care for? A client recovering from a scheduled cesarean delivery The nurse administers an injection to a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). After administering the medication, the nurse should dispose of the used needle by which method? Placing the needle and syringe in a puncture-resistant container A client has a prescription to receive 1000 mL of 5% dextrose in 0.45% sodium chloride. After gathering the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing? Closes the roller clamp on the IV tubing The nurse is caring for a client who becomes agitated and begins to pull on a surgically placed abdominal drainage tube. The primary health care provider visits and prescribes restraints if needed. Which actions are appropriate to delegate to the unlicensed assistive personnel (UAP), who has completed the facility's education about care of the restrained client? Select all that apply. Socialize with the restrained client. Remove the restraint and perform range of motion activity. Reapply the restraint after assisting the client to the bathroom. The registered nurse (RN) and a licensed practical nurse (LPN) are discussing total parenteral nutrition (TPN) with a client who is receiving TPN through a peripherally inserted central catheter (PICC). The client asks why the solution is being infused through a central catheter IV. The nurses explain that TPN is preferably infused through a central line for which reason? There is greater blood flow with a central line IV to dilute the TPN, which is a concentrated solution and needs to be diluted to avoid damage to the blood vessel. A client is being discharged to home following spinal laminectomy and fusion with insertion of a metal implant. The nurse includes which instructions about activity after discharge? Select all that apply. Avoid activities that involve pulling or pushing. Do not lift objects weighing more than 5 pounds. Do not climb stairs until after the follow-up appointment with the surgeon. The nurse is assigned to assist with caring for a client with esophageal varices who had a Sengstaken-Blakemore tube inserted because other treatment measures were unsuccessful. The nurse should check the client's room to ensure that which priority item is at the bedside? A pair of scissors The nurse is reinforcing discharge instructions to the parents of a 2-year-old child who sustained accidental burns from a hot cup of coffee. The nurse determines that the parents have correctly understood the teaching when they make which statement? "We will be sure not to leave hot liquids unattended." The nurse is instructed to complete a medication reconciliation form on a newly admitted client. Why is it important for the nurse to ensure that this process is completed accurately? It helps to make sure that the primary health care provider is aware of all of the medications the client is taking and has been taking at home. The nurse reviews the laboratory values on a child with leukemia receiving chemotherapy. The nurse notes that the platelet count is 19,000 mm3 (19 × 109/L).Based on this laboratory result, which actions should the nurse include in the plan of care? Select all that apply. Testing stools and urine for blood Using a soft toothbrush for mouth care The nurse is preparing to clean up a blood spill on the client's bedside table. The spill occurred when a blood tube containing the client's blood specimen broke. The nurse avoids doing which action when cleaning up the blood spill? Blotting up the spill with a face cloth or cloth towel A mother tells the pediatrician's office nurse that she is concerned because her children must let themselves into the house after school each day while she is at work and they feel isolated and fearful. The nurse should suggest which to the mother? "You should seek community after-school programs or activities for your children." The nurse is assigned to care for a client experiencing episodes of postural hypotension who will be discharged home soon. Which actions should the nurse take to ensure safety while transferring the client from the bed to the chair? Select all that apply. Question the client about feelings of dizziness. Put the client's shoes on to help the client avoid slipping on the floor during the transfer. Allow the client to dangle the legs in a sitting position on the bed before transfer to a chair. The nurse applies wrist restraints, prescribed to prevent a client from pulling out a nasogastric tube. How should the nurse determine that the restraints are not too constrictive? Place two fingers under the restraint to determine snugness. A 1-year-old infant is admitted to the hospital for control of tonic-clonic seizures. The nurse helps minimize the infant's risk for injury by implementing which interventions? Select all that apply. Removing any toy with bright blinking lights Keeping the sides rails of the child's bed padded Turning the infant on the side during any seizure Having oxygen and suction available at the bedside The nurse is planning to get a client out of bed for the first time after having a total hip arthroplasty (THA). What specific actions would the nurse take? Select all that apply. Place a gait belt on the client. If stretch bands are used, reinforce the correct use. Observe for any signs/symptoms of dizziness the first time the client gets out of bed. After the client sits on the side of the bed, remind the client to stand on the unaffected leg. The nurse is preparing to feed a client who is at risk for aspiration. The nurse assesses the client and uses a penlight and tongue blade to check the mouth and cheeks for pockets of food. Which action does the nurse take next? Refer to video. Click on the Question Video button to view a video showing preparation procedures. Places the client in an upright position A client with chronic pain has been taught how to operate a transcutaneous electrical nerve stimulation (TENS) unit. Which client action shows understanding of the appropriate use of the device when the level of stimulation is uncomfortable? The client adjusts the setting downward slightly. [Show Less]
- Exam
- $11.95
- 0
- 142
Musculoskeletal Saunders NCLEX with complete solution 2022
On a visit to the clinic, a client reports the onset of early symptoms of rheumatoid arthritis. The nurse should conduct a focused assessment for: 1. Limi... [Show More] ted motion of joints. 2. Deformed joints of the hands. 3. Early morning stiffness. 4. Rheumatoid nodules. 3. Initially, most clients with early symptoms of rheumatoid arthritis complain of early morning stiffness or stiffness after sitting still for a while. Later symptoms of rheumatoid arthritis include limited joint range of motion; deformed joints, especially of the hand; and rheumatoid nodules. 2. A client with rheumatoid arthritis states, "I can't do my household chores without becoming tired. My knees hurt whenever I walk." Which nursing diagnosis would be most appropriate? 1. Activity intolerance related to fatigue and pain. 2. Self-care deficit related to increasing joint pain. 3. Ineffective coping related to chronic pain. 4. Disturbed body image related to fatigue and joint pain. 1. Based on the client's complaints, the most appropriate nursing diagnosis would be Activity intolerance related to fatigue and pain. Nursing interventions would focus on helping the client conserve energy and decrease episodes of fatigue. Although the client may develop a self-care deficit related to the activity intolerance and increasing joint pain, the client is voicing concerns about household chores and difficulty around the house and yard, not self-care issues. Over time, the client may develop ineffective coping or body image disturbance as the disorder becomes chronic with increasing pain and fatigue. Of the clients listed below, who is at risk for developing rheumatoid arthritis (RA)? Select all that apply. 1. Adults between the ages of 20 and 50 years. 2. Adults who have had an infectious disease with the Epstein-Barr virus. 3. Adults that are of the male gender. 4. Adults who possess the genetic link, specifically HLA-DR4. 5. Adults who also have osteoarthritis. 1, 2, 4. Rheumatoid arthritis (RA) affects women three times more often than men, between the ages of 20 and 55 years. Research has determined that RA occurs in clients who have had infectious disease, such as the Epstein-Barr virus. The genetic link, specifically HLA-DR4, has been found in 65% of clients with RA. People with osteoarthritis are not necessarily at risk for developing rheumatoid arthritis. A client is in the acute phase of rheumatoid arthritis. Which of the following should the nurse identify as lowest priority in the plan of care? 1. Relieving pain. 2. Preserving joint function. 3. Maintaining usual ways of accomplishing tasks. 4. Preventing joint deformity. 3. Maintaining usual ways of accomplishing tasks would be the lowest priority during the acute phase. Rather, the focus is on developing less stressful ways of accomplishing routine tasks. Pain relief is a high priority during the acute phase because pain is typically severe and interferes with the client's ability to function. Preserving joint function and preventing joint deformity are high priorities during the acute phase to promote an optimal level of functioning and reduce the risk of contractures. The nurse teaches a client about heat and cold treatments to manage arthritis pain. Which of the following client statements indicates that the client still has a knowledge deficit? 1. "I can use heat and cold as often as I want." 2. "With heat, I should apply it for no longer than 20 minutes at a time." 3. "Heat-producing liniments can be used with other heat devices." 4. "Ten to 15 minutes per application is the maximum time for cold applications." 3. Heat-producing liniment can produce a burn if used with other heat devices that could intensify the heat reaction. Heat and cold can be used as often as the client desires. However, each application of heat should not exceed 20 minutes, and each application of cold should not exceed 10 to 15 minutes. Application for longer periods results in the opposite of the intended effect: vasoconstriction instead of vasodilation with heat, and vasodilation instead of vasoconstriction with cold. The client with rheumatoid arthritis tells the nurse, "I have a friend who took gold shots and had a wonderful response. Why didn't my physician let me try that?" Which of the following responses by the nurse would be most appropriate? 1. "It's the physician's prerogative to decide how to treat you. The physician has chosen what is best for your situation." 2. "Tell me more about your friend's arthritic condition. Maybe I can answer that question for you." 3. "That drug is used for cases that are worse than yours. It wouldn't help you, so don't worry about it." 4. "Every person is different. What works for one client may not always be effective for another." 4. The nurse's most appropriate response is one that is therapeutic. The basic principle of therapeutic communication and a therapeutic relationship is honesty. Therefore, the nurse needs to explain truthfully that each client is different and that there are various forms of arthritis and arthritis treatment. To state that it is the physician's prerogative to decide how to treat the client implies that the client is not a member of his or her own health care team and is not a participant in his or her care. The statement also is defensive, which serves to block any further communication or questions from the client about the physician. Asking the client to tell more about the friend presumes that the client knows correct and complete information, which is not a valid assumption to make. The nurse does not know about the client's friend and should not make statements about another client's condition. Stating that the drug is for cases that are worse than the client's demonstrates that the nurse is making assumptions that are not necessarily valid or appropriate. Also, telling the client not to worry ignores the underlying emotions associated with the question, totally discounting the client's feelings. The teaching plan for the client with rheumatoid arthritis includes rest promotion. Which of the following would the nurse expect to instruct the client to avoid during rest periods? 1. Proper body alignment. 2. Elevating the part. 3. Prone lying positions. 4. Positions of flexion. 4. Positions of flexion should be avoided to prevent loss of functional ability of affected joints. Proper body alignment during rest periods is encouraged to maintain correct muscle and joint placement. Lying in the prone position is encouraged to avoid further curvature of the spine and internal rotation of the shoulders. After teaching the client with rheumatoid arthritis about measures to conserve energy in activities of daily living involving the small joints, which of the following, if stated by the client, would indicate the need for additional teaching? 1. Pushing with palms when rising from a chair. 2. Holding packages close to the body. 3. Sliding objects. 4. Carrying a laundry basket with clinched fingers and fists. 4. Carrying a laundry basket with clinched fingers and fists is not an example of conserving energy of small joints. The laundry basket should be held with both hands opened as wide as possible and with outstretched arms so that pressure is not placed on the small joints of the fingers. When rising from a chair, the palms should be used instead of the fingers so as to distribute weight over the larger area of the palms. Holding packages close to the body provides greater support to the shoulder, elbow, and wrist joints because muscles of the arms and hands are used to stabilize the weight against the body. This decreases the stress and weight or pull on small joints such as the fingers. Objects can be slid with the palm of the hand, which distributes weight over the larger area of the palms instead of stressing the small joints of the fingers to pick up the weight of the object to move it to another place. After teaching the client with severe rheumatoid arthritis about prescribed methotrexate (Rheumatrex), which of the following statements indicates the need for further teaching? 1. "I will take my vitamins while I'm on this drug." 2. "I must not drink any alcohol while I'm taking this drug." 3. "I should brush my teeth after every meal." 4. "I will continue taking my birth control pills." 1. Because some over-the-counter vitamin supplements contain folic acid, the client should avoid self-medication with vitamins while taking methotrexate, a folic acid antagonist. Because methotrexate is hepatotoxic, the client should avoid the intake of alcohol, which could increase the risk for hepatotoxicity. Methotrexate can cause bone marrow depression, placing the client at risk for infection. Therefore, meticulous mouth care is essential to minimize the risk of infection. Contraception should be used during methotrexate therapy and for 8 weeks after the therapy has been discontinued because of its effect on mitosis. Methotrexate is considered teratogenic. A 25-year-old client taking hydroxychloroquine (Plaquenil) for rheumatoid arthritis reports difficulty seeing out of her left eye. Correct interpretation of this assessment finding indicates which of the following? 1. Development of a cataract. 2. Possible retinal degeneration. 3. Part of the disease process. 4. A coincidental occurrence. 2. Difficulty seeing out of one eye, when evaluated in conjunction with the client's medication therapy regimen, leads to the suspicion of possible retinal degeneration. The possibility of an irreversible retinal degeneration caused by deposits of hydroxychloroquine (Plaquenil) in the layers of the retina requires an ophthalmologic examination before therapy is begun and at 6-month intervals. Although cataracts may develop in young adults, they are less likely, and damage from the hydroxychloroquine is the most obvious at-risk factor. Eyesight is not affected by the disease process of rheumatoid arthritis. A client with rheumatoid arthritis tells the nurse, "I know it is important to exercise my joints so that I won't lose mobility, but my joints are so stiff and painful that exercising is difficult." Which of the following responses by the nurse would be most appropriate? 1. "You are probably exercising too much. Decrease your exercise to every other day." 2. "Tell the physician about your symptoms. Maybe your analgesic medication can be increased." 3. "Stiffness and pain are part of the disease. Learn to cope by focusing on activities you enjoy." 4. "Take a warm tub bath or shower before exercising. This may help with your discomfort." 4. Superficial heat applications, such as tub baths, showers, and warm compresses, can be helpful in relieving pain and stiffness. Exercises can be performed more comfortably and more effectively after heat applications. The client with rheumatoid arthritis must balance rest with exercise every day, not every other day. Typically, large doses of analgesics, which can lead to hepatotoxic effects, are not necessary. Learning to cope with the pain by refocusing is inappropriate. Which of the following statements should the nurse include in the teaching session when preparing a client for arthrocentesis? Select all that apply. 1. "A local anesthetic agent may be injected into the joint site for your comfort." 2. "A syringe and needle will be used to withdraw fluid from your joint." 3. "The procedure, although not painful, will provide immediate relief." 4. "We'll want you to keep your joint active after the procedure to increase blood flow." 5. "You will need to wear a compression bandage for several days after the procedure." 1, 2, 5. An arthrocentesis is performed to aspirate excess synovial fluid, pus, or blood from a joint cavity to relieve pain or to diagnosis inflammatory diseases such as rheumatoid arthritis. A local agent may be used to decrease the pain of the needle insertion through the skin and into the joint cavity. Aspiration of the fluid into the syringe can be very painful because of the size and inflammation of the joint. Usually a steroid medication is injected locally to alleviate the inflammation; a compression bandage is applied to help decrease swelling; and the client is asked to rest the joint for up to 24 hours afterwards to help relieve the pain and promote rest to the inflamed joint. The client may experience pain during this time until the inflammation begins to resolve and swelling decreases. A client with osteoarthritis will undergo an arthrocentesis on his painful edematous knee. What should be included in the nursing plan of care? Select all that apply. 1. Explain the procedure. 2. Administer preoperative medication 1 hour before surgery. 3. Instruct the client to immobilize the knee for 2 days after the surgery. 4. Assess the site for bleeding. 5. Offer pain medication. 1, 4, 5. To prepare a client for an arthrocentesis, the nurse should tell the client that a local anesthetic administered by the physician will decrease discomfort. There may be bleeding after the procedure, so the nurse should check the dressing. The client may experience pain. The nurse should offer pain medication and evaluate outcomes for pain relief. Because a local anesthetic is used, the client will not require preoperative medication. The client will rest the knee for 24 hours and then should begin range-of-motion and muscle strengthening exercises. A postmenopausal client is scheduled for a bone-density scan. To plan for the client's test, what should the nurse communicate to the client? 1. Request that the client remove all metal objects on the day of the scan. 2. Instruct the client to consume foods and beverages with a high content of calcium for 2 days before the test. 3. Inform the client that she will need to ingest 600 mg of calcium gluconate by mouth for 2 weeks before the test. 4. Tell the client that she should report any significant pain to her physician at least 2 days before the test. 1. Metal will interfere with the test. Metallic objects within the examination field, such as jewelry, earrings, and dental amalgams, may inhibit organ visualization and can produce unclear images. Ingesting foods and beverages days before the test will not affect bone mineral status. Short-term calcium gluconate intake will also not influence bone mineral status. The client may already have had chronic pain as a result of a bone fracture or from osteoporosis. A physician orders a lengthy X-ray examination for a client with osteoarthritis. Which of the following actions by the nurse would demonstrate client advocacy? 1. Contact the X-ray department and ask the technician if the lengthy session can be divided into shorter sessions. 2. Contact the physician to determine if an alternative examination could be scheduled. 3. Provide a dose of acetaminophen (Tylenol). 4. Cancel the examination because of the hard X-ray table. 1. Shorter sessions will allow the client to rest between the sessions. Changing the physician's order to a different examination will not provide the information needed for this client's treatment. Acetaminophen is a nonopioid analgesic and an antipyretic, not an anti-inflammatory agent. Thus, it would not help this client avoid the adverse effects of a lengthy X-ray examination. Although the X-ray table is hard, there are other options for making the client comfortable, rather than canceling the examination. Which of the following should the nurse assess when completing the history and physical examination of a client diagnosed with osteoarthritis? 1. Anemia. 2. Osteoporosis. 3. Weight loss. 4. Local joint pain. 4. Osteoarthritis is a degenerative joint disease with local manifestations such as local joint pain, unlike rheumatoid arthritis, which has systemic manifestation such as anemia and osteoporosis. Weight loss occurs in rheumatoid arthritis, whereas most clients with osteoarthritis are overweight. A client with osteoporosis needs education about diet and ways to increase bone density. Which of the following should be included in the teaching plan? Select all that apply. 1. Maintain a diet with adequate amounts of vitamin D, as found in fortified milk and cereals. 2. Choose good calcium sources, such as figs, broccoli, and almonds. 3. Use alcohol in moderation because a moderate intake has no known negative effects. 4. Try swimming as a good exercise to maintain bone mass. 5. Avoid the use of high-fat foods, such as avocados, salad dressings, and fried foods. 1, 2, 3. A diet with adequate amounts of vitamin D aids in the regulation, absorption, and subsequent utilization of calcium and phosphorus, which are necessary for the normal calcification of bone. Figs, broccoli, and almonds are very good sources of calcium. Moderate intake of alcohol has no known negative effects on bone density but excessive alcohol intake does reduce bone density. Swimming, biking, and other non- weight-bearing exercises do not maintain bone mass. Walking and running, which are weight-bearing exercises, do maintain bone mass. The client should eat a balanced diet but does not need to avoid the use of high-fat foods. Which of the following statements indicates that the client with osteoarthritis understands the effects of capsaicin (Zostrix) cream? 1. "I always wash my hands right after I apply the cream." 2. "After I apply the cream, I wrap my knee with an elastic bandage." 3. "I keep the cream in the cabinet above the stove in the kitchen." 4. "I also use the same cream when I get a cut or a burn." 1. Capsaicin cream, which produces analgesia by preventing the reaccumulation of substance P in the peripheral sensory neurons, is made from the active ingredients of hot peppers. Therefore, clients should wash their hands immediately after applying capsaicin cream if they do not wear gloves, to avoid possible contact between the cream and mucous membranes. Clients are instructed to avoid wearing tight bandages over areas where capsaicin cream has been applied because swelling may occur from inflammation of the arthritis in the joint and lead to constriction on the peripheral neurovascular system. Capsaicin cream should be stored in areas between 59 ° F and 86 ° F (15 ° C and 30 ° C). The cabinet over the stove in the kitchen would be too warm. Capsaicin cream should not come in contact with irritated and broken skin, mucous membranes, or eyes. Therefore it should not be used on cuts or burns. At which of the following times should the nurse instruct the client to take ibuprofen (Motrin), prescribed for left hip pain secondary to osteoarthritis, to minimize gastric mucosal irritation? 1. At bedtime. 2. On arising. 3. Immediately after a meal. 4. On an empty stomach. 3. Drugs that cause gastric irritation, such as ibuprofen, are best taken after or with a meal, when stomach contents help minimize the local irritation. Taking the medication on an empty stomach at any time during the day will lead to gastric irritation. Taking the drug at bedtime with food may cause the client to gain weight, possibly aggravating the osteoarthritis. When the client arises, he is stiff from immobility and should use warmth and stretching until he gets food in his stomach. The client diagnosed with osteoarthritis states, "My friend takes steroid pills for her rheumatoid arthritis. Why don't I take steroids for my osteoarthritis?" Which of the following is the best explanation? 1. Intra-articular corticosteroid injections are used to treat osteoarthritis. 2. Oral corticosteroids can be used in osteoarthritis. 3. A systemic effect is needed in osteoarthritis. 4. Rheumatoid arthritis and osteoarthritis are two similar diseases. 1. [Show Less]
- Exam
- $16.45
- 0
- 115
Saunders NCLEX Questions with complete solution 2022
1. Which teaching method is most effective when providing instruction to members of special populations? 1. Teach-back 2. Video instruction 3. Written m... [Show More] aterials 4. Verbal explanation 1. Answer: 1Rationale: When providing education to members of special populations, return explanation and demonstration (teach-back) are of particular importance to ensure safety and mutual understanding. This method is the most reliable in confirming client understanding of the instructions. Video instruction, written materials, and verbal explanation are helpful and may be incorporated with the teach-back method. Test-Taking Strategy: Note the strategic words, most effective. Note that the correct option—the teach-back method—is the umbrella option, and encompasses all other options. Recall that asking the client to perform return demonstration is the best way to confirm understanding. 2. Which health concern(s) should the nurse be aware of as risk factors when caring for clients of African American descent? Select all that apply. 1. Cancer 2. Obesity 3. Hypertension 4. Heart disease 5. Hypothyroidism 6. Diabetes mellitus 2. Answer: 1, 2, 3, 4, 6 Rationale: Obesity, diabetes mellitus, hypertension, heart disease, asthma, and cancer are prevalent among this population. Hypothyroidism is not a particular risk factor. It is important to understand risk factors associated with health and the interplay of genetics, which can result in trends or patterns for specific ethnic groups. Test-Taking Strategy: Note the subject, health concerns for African Americans. It is necessary to know the health risks associated with this group and that hypothyroidism is not a concern in order to answer this question correctly. 3. The nurse is planning care for a client of Native Hawaiian descent who recently had a baby. The nurse develops a teaching plan and includes information about which measure that is related to a newborn complication within this ethnic group? 1. Safe sleeping 2. Car seat safety 3. Breast-feeding 4. Baby-proofing 3. Answer: 1 Rationale: The Native Hawaiian population has a disproportionately higher rate of infant mortality compared with other ethnic groups. Sudden infant death syndrome (SIDS) is a major cause of infant mortality. Safe sleeping is an important measure to prevent this newborn complication. Car seat safety, breast-feeding, and baby-proofing are important safety measures but are not specific to Native Hawaiians. Test-Taking Strategy: Note the subject, newborn teaching and a newborn complication for the Native Hawaiian population. It is necessary to know that infant mortality and SIDS is higher in this population. Recalling that safe sleeping is an important measure in decreasing infant mortality will direct you to the correct option. 4. The nurse is planning care for an assigned client. The nurse should include information in the plan of care about prevention of human immunodeficiency virus (HIV) for which individuals specifically at risk? 1. Lesbian persons 2. Men-who-have-sex-with-men (MSM) 3. Women-who-have-sex-with-women (WSW) 4. Female-to-male (FTM) transgender persons 4. Answer: 2 Rationale: MSM (men-who-have-sex-with-men) are at a higher risk for HIV and acquired immunodeficiency syndrome (AIDS). Although anyone who is sexually active should be counseled on prevention of sexually transmitted infection, the other populations mentioned are not at an increased risk for HIV/AIDS. Test-Taking Strategy: Note that options 1 and 3 are comparable or alike and therefore can be eliminated. Recalling that MTF (male-to-female) rather than FTM (female-to-male) are at risk for HIV/AIDS will assist you in eliminating option 4. 5. Which therapeutic communication technique is most helpful when working with transgender persons? 1. Using open-ended questions 2. Using their first name to address them 3. Using pronouns associated with birth sex 4. Anticipating the client's needs and making suggestions 5. Answer: 1 Rationale: The use of open-ended questions is most helpful in communicating with transgender persons because it assists in refraining from judgment and allows the client the opportunity to express their thoughts and feelings. The nurse should address the client with the name that the client prefers, so the first name may not necessarily be their preference. For the transgender person, it is likely that they would like to be addressed using pronouns associated with the sex they identify with now, which typically is not their birth sex. Anticipating the client's needs and making suggestions may be seen as passing judgment, so the nurse should refrain from doing this. Test-Taking Strategy: Note the strategic word, most. Recalling that clarification with the client regarding name preference for any client will assist you in eliminating option 2. Recalling that use of pronouns associated with birth sex is inappropriate will assist you in eliminating option 3. Noting the words making suggestions in option 4 will assist you in eliminating this option. 6. Which special population should be targeted for breast cancer screening by way of mammography? Select all that apply. 1. Male-to-female (MTF) 2. Female-to-male (FTM) 3. Men-who-have-sex-with-men (MSM) 4. Women-who-have-sex-with-men (WSM) 5. Women-who-have-sex-with-women (WSW) 6. Answer: 1, 2, 4, 5 Rationale: Transgender persons who have undergone sexual reassignment surgery should have the respective preventive screenings. For example, MTF should have breast cancer screening by way of mammography if they are older than 50 years. Additionally, FTM should still have mammography routinely as indicated due to the risk for residual breast tissue to develop cancerous growth. WSW and WSM should have screening as well. Test-Taking Strategy: Note the subject, indications for mammography. Recalling that this test is primarily indicated for females will direct you to the correct options. 7. The nurse is volunteering with an outreach program to provide basic health care for homeless people. Which finding, if noted, should be addressed first? 1. Blood pressure 154/72 mm Hg 2. Visual acuity of 20/200 in both eyes 3. Random blood glucose level of 206 mg/dL (11.47 mmol/L) 4. Complaints of pain associated with numbness and tingling in both feet 7. Answer: 4 Rationale: The nurse should address the complaints of pain and numbness and tingling in both feet first with this population. If the client perceives value to the service provided, they will be more likely to return for follow-up care. While the blood pressure, blood glucose, and vision results are concerning, the client's stated concern should be addressed first. Test-Taking Strategy: Note the subject, the finding to be addressed, and focus on the strategic word, first. Recalling that adherence is a problem for this population will direct you to the correct option. Also note that the correct option is the only subjective finding. 8. The nurse is preparing discharge resources for a client being discharged to the homeless shelter. When looking at the discharge medication reconciliation form, the nurse determines there is a need for follow-up if which medication was prescribed? 1. Glipizide 2. Lisinopril 3. Metformin 4. Beclomethasone 8. Answer: 1 Rationale: There are a number of medications that should be avoided, if possible, for the homeless person due to the safety risks. Glipizide is an oral hypoglycemic medication and is classified as a sulfonylurea. A major side effect of this medication is hypoglycemia, which presents a safety risk to the homeless person. Lisinopril is an angiotensin-converting enzyme inhibitor. Although there are side effects that should be included in discharge instructions, there is less of a threat to safety with this medication, and the benefits of it are important. Metformin is an oral biguanide and is used for type 2 diabetes mellitus. Hypoglycemia is less of a concern with this medication compared with other oral hypoglycemics. Beclomethasone is an inhaled corticosteroid used for obstructive lung disease, and although there are side effects that the client should know about, there is not a particular safety risk associated with this medication for the homeless person. Test-Taking Strategy: Note the strategic words, need for follow-up. Specific knowledge about the medications identified in the options and knowledge of the medications that should be avoided with the homeless clients is needed to answer this question. Remember that sulfonylureas present the risk of hypoglycemia. 9. The nurse is completing the admission assessment for a client who is intellectually disabled. Which part of the client encounter may require more time to complete? 1. The history 2. The physical assessment 3. The nursing plan of care 4. The readmission risk assessment 9. Answer: 1 Rationale: Intellectually disabled clients tend to be poor historians, and it may be necessary to take more time to ask questions in a variety of different ways when collecting the history data. The physical assessment, nursing plan of care, and readmission risk assessment portions, although they rely on the history, take less time because they require less client questioning. Test-Taking Strategy: Note the subject, conducting an admission assessment for an intellectually disabled client and the part that may take more time to complete. Recalling that individuals in this special population group are poor historians and that use of questioning in a variety of ways may be necessary will direct you to the correct option. 10. The nurse working in a correctional facility is caring for a new prisoner. The client asks about health risks associated with living in a prison. How should the nurse respond? 1. "Health care is very limited in the prison setting." 2. "Living in a prison isn't different than living at home." 3. "Living in a prison can predispose a person to different health conditions." 4. "Living in a prison is similar to living in a condominium complex or dormitory." 10. Answer: 3 Rationale: The environment of a prison can predispose a person to different health conditions, such as tuberculosis, human immunodeficiency syndrome, sexually transmitted infections, or other infectious diseases. Option 1 does not address the client's question. Options 2 and 4 convey incorrect information. Test-Taking Strategy: Note the subject, health conditions associated with living in a prison. Remember that the prison is a confined environment, and a variety of infectious diseases are prevalent. 11. The nurse is caring for a female client in the emergency department who presents with a complaint of fatigue and shortness of breath. Which physical assessment findings, if noted by the nurse, warrant a need for follow-up? 1. Reddened sclera of the eyes 2. Dry flaking noted on the scalp 3. A reddish-purple mark on the neck 4. A scaly rash noted on the elbows and knees 11. Answer: 3 Rationale: The client in this question should be screened for abuse. Battered women experience bruises, particularly around the eyes, red or purple marks on the neck, sprained or broken wrists, chronic fatigue, shortness of breath, muscle tension, involuntary shaking, changes in eating and sleeping, sexual dysfunction, and fertility issues. Mental health issues can also arise, including post-traumatic stress disorder, nightmares, anxiety, uncontrollable thoughts, depression, anxiety, low self- esteem, and alcohol and drug abuse. Reddened sclera, a dry rash on the elbows, and flaking of the scalp do not pose an indication of abuse. Test-Taking Strategy: Note the strategic words, need for follow-up. Also focus on the data in the question and select the option that indicates the most concern and is indicative of abuse. Remember that battered women often present with bruising around the eyes or on the neck. 12. The nurse working in a community outreach program for foster children plans care knowing that which health conditions are common in this population? Select all that apply. 1. Asthma 2. Claustrophobia 3. Sleep problems 4. Bipolar disorder 5. Aggressive behavior 6. Attention-deficit hyperactivity disorder (ADHD) 12. Answer: 3, 4, 5, 6 Rationale: Foster children are at risk for a variety of health conditions later in life, including ADHD, aggressive behavior, anxiety disorder, bipolar disorder, depression, mood disorder, post-traumatic stress disorder, reactive detachment disorder, sleep problems, prenatal drug and alcohol exposure, and personality disorder. Claustrophobia and asthma are not specifically associated with foster children. Test-Taking Strategy: Note the subject, health concerns for foster children. Recall that mental health is a major concern for this population. This will assist in directing you to the correct options. 13. The nurse planning care for a military veteran should prioritize nursing interventions targeted at managing which condition, if present, that commonly occurs in this population? 1. Hypertension 2. Hyperlipidemia 3. Substance abuse disorder 4. Post-traumatic stress disorder 13. Answer: 4 Rationale: Post-traumatic stress disorder (PTSD) is extremely common in this population. Identifying and treating mental health disorders assists in mitigating suicide risk. Treatment of comorbid conditions such as PTSD may also help address any substance use disorder. Use of screening tools in identifying substance use disorder is helpful. Treatment of PTSD includes exposure therapy, psychotherapy, and family/group therapy. Hypertension and hyperlipidemia are important but not the priority; the risk of suicide and other safety concerns associated with PTSD are the priority for this population. Test-Taking Strategy: Note the strategic word, prioritize. This phrase indicates that although all options may be important, one option is a priority due to safety considerations. Also note that options 1 and 2 are comparable or alike and therefore can be eliminated. Although substance abuse may be a concern, PTSD is the priority. 14. The nurse caring for a refugee considers which health care need a priority for this client? 1. Access to housing 2. Access to clean water 3. Access to transportation 4. Access to mental health care services 14. Answer: 4 Rationale: Mental health problems are the primary issue for this population as a result of tortuous events. While all other options are important for all clients, they do not address the specific needs of this special population. Test-Taking Strategy: Note the strategic word, priority. This indicates that all options are important and are most likely correct. It is necessary to recall that due to the potential trauma experienced by refugees, mental health is a priority. 15. Which action by the nurse will best facilitate adherence to the treatment regimen for a client with a chronic illness? 1. Arranging for home health care 2. Focusing on managing a single illness at a time 3. Communicating with one provider only to avoid confusion for the client 4. Allowing the client to teach a support person about their treatment regimen 15. Answer: 1 Rationale: Nursing follow-up visits are important in promoting health for individuals with chronic illness; therefore, arranging for home health care is an important strategy. Focusing on a single illness does not effectively manage an individual with multiple chronic diseases—rather, the "big picture" needs to be understood in managing these clients. Interprofessional collaboration is important in safely managing individuals with chronic diseases, and often involves consulting with specialist providers. Nurses play a key role in facilitating communication between providers and specialists. Inclusion of the client and support person(s) in health care decisions helps increase adherence to a complex health care regimen, and the nurse should be the facilitator of this communication. [Show Less]
- Exam
- $11.45
- 0
- 203
Saunders NCLEX questions & answers 2022/2023
The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this method, which questions would the nurse ask the client? The PQRST... [Show More] U method is one method of assessing pain. With this method, the nurse asks about the following: Precipitating factors (option 6); Quality of the pain (option 3); Region or Radiation of the pain (option 1); Severity of the pain; Timing of the pain (continuous or intermittent); and How the pain affects you (option 4). Options 2 and 5 may be questions that would be asked; however, these are not a part of the PQRSTU method. The nurse is preparing to administer furosemide (Lasix) to a client with a diagnosis of heart failure. Which is the most important laboratory test result for the nurse to check before administering this medication? 1-Blood urea nitrogen 2-Cholesterol level 3-Potassium level 4-Creatinine level Furosemide is a loop diuretic. The medication causes a decrease in the client's electrolytes, especially potassium, sodium, and chloride. Administering furosemide to a client with low electrolyte levels could precipitate ventricular dysrhythmias. Options 1 and 4 reflect renal function. The cholesterol level is unrelated to the administration of this medication. A nurse caring for a client with a diagnosis of gastrointestinal (GI) bleeding reviews the client's laboratory results and notes a hematocrit level of 30%. Which action should the nurse take? 1-Report the abnormally low level. 2-Report the abnormally high level. 3-Inform the client that the laboratory result is normal. 4-Place the normal report in the client's medical record. 1-Report the abnormally low level. The normal hematocrit level in a male ranges from 42% to 52%, and 35% to 47 % in a female, depending on age. A hematocrit level of 30% is a low level and would be reported to the health care provider because it indicates blood loss; therefore options 2, 3, and 4 are incorrect. A nurse provides dietary instructions to a client who will be taking warfarin sodium (Coumadin). The nurse should tell the client to avoid which food item? 1-Grapes 2-Spinach 3-Watermelon 4-Cottage cheese 2-Spinach Warfarin sodium is an anticoagulant. Anticoagulant medications act by antagonizing the action of vitamin K, which is needed for clotting. When a client is taking an anticoagulant, foods high in vitamin K often are omitted from the diet. Vitamin K-rich foods include green leafy vegetables, fish, liver, coffee, and tea. A client who has been receiving total parenteral nutrition (TPN) by way of a central venous access device complains of chest pain and dyspnea. The nurse quickly assesses the client's vital signs and notes that the pulse rate has increased and the blood pressure has dropped. The nurse determines that the client is most likely experiencing which problem? 1-Sepsis 2-Air embolism 3-Fluid overload 4-Fluid imbalance 2-Air embolism The signs and symptoms of air embolism include chest pain, dyspnea, hypoxia, anxiety, tachycardia, and hypotension. The nurse also may hear a loud churning sound over the pericardium on auscultation of the client's chest. The signs and symptoms of sepsis include fever, chills, and general malaise. Fluid overload causes increased intravascular volume, which increases the blood pressure and the pulse rate as the heart tries to pump the extra fluid volume. Fluid overload also causes neck vein distention and shifting of fluid into the alveoli, resulting in lung crackles. The signs and symptoms of a fluid imbalance depend on the type of imbalance the client is experiencing. A client who is receiving intravenous (IV) fluid therapy complains of burning and a feeling of tightness at the IV insertion site. On assessment, the nurse detects coolness and swelling at the site and notes that the IV rate has slowed. The nurse determines that which complication has occurred? 1-Infection 2-Phlebitis 3-Infiltration 4-Thrombosis An infiltrated IV line is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, and swelling at the IV site result when IV fluid is deposited in the subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of IV solution will slow down or stop. The corrective action is to remove the catheter and start a new IV line at another site. The conditions identified in options 1, 2, and 4 are likely to be accompanied by warmth at the site, not coolness. A nurse provides instructions to a preoperative client about the use of an incentive spirometer. The nurse determines that the client needs further instruction if the client indicates that he or she will take which action? 1-Sit upright when using the device. 2-Inhale slowly, maintaining a constant flow. 3-Place the lips completely over the mouthpiece. 4-After maximal inspiration, hold the breath for 10 seconds and then exhale. 4-After maximal inspiration, hold the breath for 10 seconds and then exhale. For optimal lung expansion with the incentive spirometer, the client should assume a semi-Fowler's or high Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. When maximal inspiration is reached, the client should hold the breath for 2 or 3 seconds and then exhale slowly The nurse is monitoring a client who has a closed chest tube drainage system. The nurse notes fluctuation of the fluid level in the water-seal chamber during inspiration and expiration. On the basis of this finding, the nurse should make which interpretation? 1-There is a leak in the system. 2-The chest tube is functioning as expected. 3-The amount of suction needs to be decreased. 4-The occlusive dressing at the insertion site needs reinforcement. 2-The chest tube is functioning as expected. The presence of fluctuation of the fluid level in the water-seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if the suction is not working properly, or if the lung has re-expanded. Options 1, 3, and 4 are incorrect interpretations of the finding. An air leak may cause excessive bubbling in the water seal chamber. Excessive and vigorous bubbling in the suction control chamber may indicate that the amount of suction needs to be decreased. The status of the dressing is not specifically related to the presence of fluctuation of the fluid level in the water-seal chamber A nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. The nurse immediately applies sterile gauze over the chest tube insertion site. Which is the nurse's next action? 1-Call the health care provider. 2-Replace the chest tube system. 3-Obtain a pulse oximetry reading. 4-Place the client in a Trendelenburg position 1-Call the health care provider. If the chest drainage system is dislodged from the insertion site, the nurse immediately applies sterile gauze over the site and calls the health care provider. The nurse would maintain the client in an upright position. A new chest tube system may be attached if the tube requires insertion, but this would not be the next action. Pulse oximetry readings would assist in determining the client's respiratory status, but the priority action would be to call the health care provider in this emergency situation. A nurse reviews the medication history of a client and notes that the client is taking leflunomide (Arava). During assessment of the client, the nurse should ask which question to determine the effectiveness of this medication? 1-"Do you have any joint pain?" 2-"Are you having any diarrhea?" 3-"Are you experiencing heartburn?" 4-"Do you have frequent headaches?" 1-"Do you have any joint pain?" Leflunomide is an immunomodulatory agent and has an anti-inflammatory action. The medication provides symptomatic relief of rheumatoid arthritis. Diarrhea can occur as a side effect of the medication. Options 2, 3, and 4 are unrelated to the action, use, or effectiveness of the medication. A nurse is checking lochia discharge in a woman in the immediate postpartum period. The nurse notes that the lochia is bright red and contains some small clots. Based on this data, the nurse should make which interpretation? 1-The client is hemorrhaging. 2-The client needs to increase oral fluids. 3-The client is experiencing normal lochia discharge. 4-The client's health care provider needs to be notified of the finding. 3-The client is experiencing normal lochia discharge. Lochia, the uterine discharge present after birth, initially is bright red and may contain small clots. During the first 2 hours after birth, the amount of uterine discharge should be approximately that of a heavy menstrual period. After that time, the lochial flow should steadily decrease, and the color of the discharge should change to a pinkish red or reddish brown. Because this is a normal, expected occurrence, options 1, 2, and 4 are incorrect. A nulliparous woman asks the nurse when she will begin to feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately how many weeks of gestation? 1-5 weeks 2-9 weeks 3-13 weeks 4-18 weeks 4-18 weeks The first recognition of fetal movements, or feeling life, by the multiparous woman may occur as early as 14 to 16 weeks' gestation. The nulliparous woman may not notice these sensations until the 18 weeks' gestation or later. The first recognition of fetal movement is called quickening. A nurse is performing a vaginal assessment of a pregnant woman who is in labor. The nurse notes that the umbilical cord is protruding from the vagina. The nurse would immediately take which action? 1-Administer oxygen to the woman. 2-Transport the woman to the delivery room. 3-Place an external fetal monitor on the woman. 4-Exert upward pressure against the presenting part using a gloved hand. 4-Exert upward pressure against the presenting part using a gloved hand. If the umbilical cord is protruding from the vagina, no attempt should be made to replace it because doing so could traumatize it and further reduce blood flow. The nurse would place a gloved hand into the vagina to the cervix and exert upward pressure against the presenting part to relieve compression of the cord. The nurse also would wrap the cord loosely in a sterile towel saturated with warm, sterile normal saline solution. Oxygen, 8 to 10 L/min by face mask, would be administered to the mother to increase fetal oxygenation, and the woman would be prepared for immediate delivery. However, the immediate action is to relieve pressure on the cord. The woman should already have an external fetal monitor in place. A nurse is assessing a woman in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which finding would the nurse expect to note if abruptio placentae is present? 1-Soft uterus 2-Abdominal pain 3-Nontender uterus 4-Painless vaginal bleeding 2-Abdominal pain Classic signs and symptoms of abruptio placentae include vaginal bleeding, abdominal pain, and uterine tenderness and contractions. Mild to severe uterine hypertonicity is present. Pains is mild to severe and either localized or diffuse over one region of the uterus, with a board-like abdomen. Painless vaginal bleeding and a soft, nontender uterus in the second or third trimester of pregnancy are signs of placenta previa. A nurse in the labor room is caring for a client who is in the first stage of labor. On assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Based on this finding, which is the appropriate nursing action? 1-Contact the health care provider. 2-Place the mother in a Trendelenburg position. 3-Administer oxygen to the client by face mask. 4-Document the findings and continue to monitor fetal patterns 4-Document the findings and continue to monitor fetal patterns Early deceleration of the FHR refers to a gradual decrease in the heart rate, followed by a return to baseline, in response to compression of the fetal head. It is a normal and benign finding. Because early decelerations are considered benign, interventions are not necessary. Therefore, options 1, 2, and 3 are unnecessary. A woman in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home. The home care nurse teaches the woman about the signs that need to be reported to the health care provider. The nurse should tell the woman to call the health care provider if which occurs? 1-Urine tests negative for protein. 2-Fetal movements are more than four per hour. 3-Weight increases by more than 1 pound in a week. 4-The blood pressure reading is ranging between 122/80 and 132/88 mm Hg. 3-Weight increases by more than 1 pound in a week. The nurse would instruct the client to report any increase in blood pressure, protein in the urine, weight gain greater than 1 pound per week, or edema. The client also is taught how to count fetal movements and is instructed that decreased fetal activity (three or fewer movements per hour) may indicate fetal compromise and should be reported. A woman in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The woman tells the nurse that she frequently has leg cramps, primarily when she is reclining. Once thrombophlebitis has been ruled out, the nurse should tell the woman to implement which measure to alleviate the leg cramps? 1-Apply heat to the affected area. 2-Take acetaminophen (Tylenol) every 4 hours. 3-Self-administer calcium carbonate tablets three times daily. 4-Purchase a chewable antacid that contains calcium and take a tablet with each meal. 1-Apply heat to the affected area. Leg cramps may be a result of compression of the nerves supplying the legs by the enlarging uterus, a reduced level of diffusible serum calcium, or an increase in serum phosphorus. In the pregnant woman who complains of leg cramps, the nurse would perform further assessments to ensure that the client is not experiencing thrombophlebitis. Once this has been ruled out, the nurse would instruct the woman to place heat on the affected area, dorsiflex the foot until the spasm relaxes, or stand and walk. The health care provider may prescribe oral supplementation with calcium carbonate tablets or calcium hydroxide gel with each meal to increase the calcium level and lower the phosphorus level, but the nurse would not prescribe these or any other medications. A nurse is preparing a pregnant woman for a transvaginal ultrasound examination. The nurse should tell the woman that which will occur? 1-She will feel some pain during the procedure. 2-She will be placed in a supine left side-lying position. 3-She will feel some pressure when the vaginal probe is moved. 4-She will need to drink 2 quarts of water to attain a full bladder 3-She will feel some pressure when the vaginal probe is moved. Transvaginal ultrasonography, in which a lubricated probe is inserted into the vagina, allows evaluation of the pelvic anatomy. A transvaginal ultrasound examination is well tolerated by most women because it alleviates the need for a full bladder to perform the test. The woman is placed in a lithotomy position or with her pelvis elevated by towels, cushions, or a folded blanket. The procedure is not physically painful, although the woman may feel pressure as the probe is moved. A client with portal-systemic encephalopathy is receiving oral lactulose (Chronulac) daily. The nurse should check which item to determine the effectiveness of this medication? 1-Lung sounds 2-Blood pressure 3-Blood ammonia level 4-Serum potassium level 3-Blood ammonia level Lactulose is a hyperosmotic laxative and ammonia detoxicant. It is used to prevent or treat portal-systemic encephalopathy, including hepatic precoma and coma. It also is used to treat constipation. The medication retains ammonia in the colon (decreases the blood ammonia concentration), producing an osmotic effect. It promotes increased peristalsis and bowel evacuation, expelling ammonia from the colon. This medication has no effect on lung sounds, the blood pressure, or the serum potassium level. The nurse notes that a client is receiving lamivudine (Epivir). The nurse determines that this medication has been prescribed to treat which condition? 1-Pancreatitis 2-Pharyngitis 3-Tonic-clonic seizures 4-Human immunodeficiency virus (HIV) 4-Human immunodeficiency virus (HIV) Lamivudine is a nucleoside reverse transcriptase inhibitor and antiviral medication. It slows HIV replication and reduces the progression of HIV infection. It also is used to treat chronic hepatitis B and provide prophylaxis in health care workers who are at risk of acquiring HIV infection after occupational exposure to the virus. This medication is not used to treat the conditions identified in options 1, 2, and 3. A nurse notes that a client is taking lansoprazole (Prevacid). On assessment of the client, the nurse should ask which question to determine the effectiveness of this medication? 1-"Has your appetite increased?" 2-"Are you experiencing any heartburn?" 3-"Do you have any problems with vision?" 4-"Do you experience any leg pain when walking?" 2-"Are you experiencing any heartburn?" Lansoprazole is a gastric acid pump inhibitor that is used to treat gastric and duodenal ulcers, erosive esophagitis, and hypersecretory conditions. It also is used to treat gastroesophageal reflux disease (GERD). It is not used to treat problems with appetite, visual problems, or leg pain. A client who has been hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is the appropriate response by the nurse? 1-"Why do you believe this?" 2-"Tell me more about the details of your belief." 3-"I hear what you are saying, but I don't share your belief." 4-"If you want a pass for tomorrow evening's movie, you'd better turn that light off this minute." 3-"I hear what you are saying, but I don't share your belief." Paranoid beliefs are coping mechanisms used by the client and therefore are not easily relinquished. It is important not to support the belief and not to ridicule, argue, or criticize it. Option 1 places the client in a defensive position by asking "why." Option 2 encourages the client to expound on the belief when discussion should instead be limited. Option 4 threatens the client. A client who has just received a diagnosis of asthma says to the nurse, "This condition is just another nail in my coffin." Which response by the nurse is therapeutic? 1-"Do you think that having asthma will kill you?" 2-"You seem very distressed over learning you have asthma." 3-"I'm not going to work with you if you can't view this as a challenge rather than a 'nail in your coffin.'" 4-"Asthma is a very treatable condition. It is important to properly administer your medications. Let's practice with your inhalant." 2-"You seem very distressed over learning you have asthma." Clients who have learned that they have a chronic illness may exhibit denial, anger, or sarcasm because of fear associated with the chronic illness. It is important for the nurse to convey an accepting attitude to enhance mutual respect and trust. Option 1 reflects and paraphrases the client's words but is somewhat sarcastic. Option 3 is punitive in its approach, threatens the client, and sarcastically quotes the client's words. Option 4 lectures the client and does not deal directly with expressed concerns. An older client is seen in the clinic for a physical examination. Laboratory studies reveal that the hemoglobin and hematocrit levels are low, indicating the need for further diagnostic studies and a blood transfusion. The client is a Jehovah's Witness and refuses to have a blood transfusion. The nurse should take which most appropriate action? 1-Try to convince the client of the need for the transfusion. 2-Speak to the family regarding the need for a blood transfusion. 3-Support the client's decision not to receive a blood transfusion. 4-Discuss with the client the results of the hemoglobin and hematocrit levels compared with normal levels. 3-Support the client's decision not to receive a blood transfusion. A client's cultural and ethnic background influences the response to health, illness, surgery, and death. Awareness of cultural differences enhances the nurse's knowledge of how a health care experience may be perceived by the client or family. In the Jehovah's Witness religion, the administration of blood and blood products is forbidden; therefore the nurse would support the client's decision. Trying to convince the client of the need for the blood transfusion is inappropriate and does not respect the client's cultural beliefs. Speaking to the family is a violation to the client's right to confidentiality; in addition, it does not respect the client's cultural beliefs. Discussing the results of laboratory values is an indirect way of trying to convince the client of the need for a blood transfusion, which again is inappropriate and does not respect the client's cultural beliefs. A postpartum woman with mastitis in the right breast complains that the breast is too sore for her to breast-feed her infant. The nurse should tell the client to implement which measure? 1-Pump both breasts and discard the milk. 2-Bottle-feed the infant on a temporary basis. 3-Breast-feed from the left breast and gently pump the right breast. 4-Stop breast-feeding from both breasts until this condition resolves. 3-Breast-feed from the left breast and gently pump the right breast. A postpartum woman with mastitis in the right breast complains that the breast is too sore for her to breast-feed her infant. The nurse should tell the client to implement which measure? A nurse is monitoring an infant for signs of increased intracranial pressure (ICP). On assessment of the fontanelles, the nurse notes that the anterior fontanelle bulges when the infant is sleeping. Based on this finding, which is the priority nursing action? 1-Increase oral fluids. 2-Document the finding. 3-Notify the health care provider. 4-Place the infant supine in a side-lying position. 3-Notify the health care provider. The anterior fontanelle is diamond shaped and is located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. A larger-than-normal fontanelle may be a sign of increased ICP within the skull. Although the anterior fontanelle may bulge slightly when the infant cries, bulging at rest may indicate increased ICP. Options 1 and 4 are inaccurate interventions and will not be helpful. Although the nurse would document the finding, the priority action would be to report the finding to the health care provider. The nurse is caring for a client who is receiving oxytocin (Pitocin) for induction of labor and notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, the nurse should take which action first? 1-Stop the oxytocin infusion. 2-Check the client's blood pressure. 3-Check the client for bladder distention. 4-Place the client in a side-lying position 1-Stop the oxytocin infusion. Oxytocin stimulates uterine contractions and is used to induce labor. If uterine hypertonicity or a nonreassuring FHR pattern occurs, the nurse needs to intervene to reduce uterine activity and increase fetal oxygenation. The oxytocin infusion is stopped, the client is placed in a side-lying position, and oxygen by face mask at 8 to 10 L/min is administered. The health care provider is notified. The nurse would monitor the client's blood pressure and intake and output; however, the nurse would first stop the infusion. A nurse performs an assessment of a pregnant woman who is receiving intravenous magnesium sulfate for management of preeclampsia and notes that the woman's deep tendon reflexes are absent. On the basis of this finding, the nurse should make which interpretation? 1-The infusion rate needs to be increased. 2-The magnesium sulfate is effective. 3-The woman is experiencing cerebral edema. 4-Magnesium toxicity can occur as a result of magnesium sulfate therapy. Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, sudden decrease in fetal heart rate or maternal heart rate or both, and sudden drop in blood pressure. An absence of reflexes indicates magnesium excess. The infusion rate therefore would not be increased. Hyperreflexia indicates increased cerebral edema. The woman is experiencing magnesium excess. Methylergonovine (Methergine) is prescribed for a woman with postpartum hemorrhage caused by uterine atony. Before administering the medication, the nurse should check which most important client parameter? 1-Lochial flow 2-Urine output 3-Temperature 4-Blood pressure 4-Blood pressure Methylergonovine is an ergot alkaloid used for postpartum hemorrhage. It stimulates contraction of the uterus and causes arterial vasoconstriction. Ergot alkaloids are avoided in women with significant cardiovascular disease, peripheral disease, hypertension, eclampsia, or preeclampsia. Such conditions are worsened by the vasoconstrictive effects of the ergot alkaloids. The nurse would assess the woman's blood pressure before administering the medication and would follow agency protocols regarding withholding of the medication. Options 1, 2, and 3 are items that are assessed in the postpartum period, but they are unrelated to the use of this medication. A nurse is monitoring a newborn infant who has been circumcised. The nurse notes that the infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which is the priority nursing action? 1-Reinforce the dressing. 2-Document the findings. 3-Contact the health care provider. 4-Swab the drainage and send the sample to the laboratory for culture. 3-Contact the health care provider. Complications after circumcision include bleeding, failure to urinate, displacement of the Plastibell, and infection (indicated by a fever and a purulent or foul-smelling drainage). If signs of infection occur, the health care provider is notified. The nurse would change, not reinforce, the dressing; reinforcing the dressing leaves the foul smelling drainage in contact with the surgical site. The nurse would document the findings, but this is not the priority item. The health care provider will prescribe a culture if it is necessary; it is not within the realm of nursing responsibilities to prescribe a diagnostic test. The nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement which type of precautions? 1-Enteric 2-Contact 3-Droplet 4-Neutropenic 3-Droplet A major priority in nursing care for a child with suspected meningitis is to administer the appropriate antibiotic as soon as it is prescribed. The child will be placed in a private room, with droplet transmission precautions, for at least 24 hours after antibiotics are given. Enteric, contact, and neutropenic precautions are not associated with the mode of transmission of meningitis. Enteric precautions are instituted when the mode of transmission is through the gastrointestinal tract. Contact precautions are instituted when contact with infectious items or materials is likely. Neutropenic precautions are instituted when the client has a low neutrophil count. The clinic nurse reads the results of a tuberculin skin test performed on a 5-year-old child who is at low risk for contracting tuberculosis. The results indicate an area of induration measuring 10 mm. How would the nurse interpret these results? 1-Positive 2-Negative 3-Inconclusive 4-Definitive and requiring a repeat test 2-Negative Induration measuring 15 mm or greater is considered a positive result in a child 4 years of age or older who has no associated risk factors. Options 1, 3, and 4 are incorrect interpretations. [Show Less]
- Exam
- $13.45
- 0
- 158
Saunder's Comprehensive NCLEX Review Practice Questions with correct answers graded A+
Which teaching method is most effective when providing instruction to members of special populations? 1. Teach-back 2. video instruction 3. written mate... [Show More] rials 4. verbal explanation 1. Teach-back Rationale: When providing education to members of special populations, return explanation and demonstration (teach-back) of are particular importance to ensure safety and mutual understanding. This method is the most reliable in confirming the client understands the instructions. Which health concerns should the nurse be aware of as risk factors when caring for clients of African American descent? Select all that apply: 1. cancer 2. obesity 3. hypertension 4. heart disease 5. hypothyroidism 6. diabetes mellitus 1, 2, 3, 4, 6 Rationale: obesity, diabetes mellitus, hypertension, heart disease, asthma, and cancer are prevalent among African Americans. The nurse is planning care for a client of Native Hawaiian descent who recently had a baby. The nurse develops a teaching plan and includes info about which measure that's related to a newborn complication within this ethnic group? 1. safe sleeping 2. car seat safety 3. breast-feeding 4. baby-proofing 1. Safe sleeping Rationale: The native Hawaiian population has a disproportionately higher rate of infant mortality compared with other ethnic groups. Sudden Infant Death Syndrome (SIDS) is a major cause of infant mortality. Safe sleeping is an important measure to prevent this newborn complication. The nurse is planning care for an assigned client. The nurse should include info in the plan of care about the prevention of HIV for which individuals specifically at risk? 1. lesbian persons 2. men-who-have-sex-with-men (MSM) 3. women-who-have-sex-with-women (WSW) 4. Female-To-Male (FTM) transgender persons 2. MSM Rationale: MSM (men who have sex with men) are at a higher risk for HIV and AIDS. Which therapeutic communication technique is most helpful when working with transgender persons? 1. using open-ended questions 2. using their first name to address them 3. using pronouns associated with birth sex 4. anticipating the client's needs and making suggestions 1. Using open-ended questions Rationale: The use of open-ended questions is the most helpful in communicating with transgender persons because it assists in refraining from judgment and allows the client the opportunity to express their thoughts and feelings. Which special population should be targeted for breast cancer screening by way of mammography? Select all that apply: 1. male-to-female (MTF) 2. female-to-male (FTM) 3. men-who-have-sex-with-men (MSM) 4. women-who-have-sex-with-men (WSM) 5. women-who-have-sex-with-women (WSW) 1, 2, 4, 5 Rationale: Transgender persons who have undergone sexual reassignment surgery should have the respective preventive screenings. WSW and WSM should also have screenings. The nurse is volunteering with an outreach program to provide basic healthcare for homeless people. Which finding, if noted, should be addressed first? 1. BP 154/72 2. visual acuity of 20/200 in both eyes 3. random blood glucose level of 206 4. complaints of pain associated with numbness and tingling in both feet 4. complaints of pain associated with numbness and tingling in both feet Rationale: With this population, the complaints of pain associated with numbness and tingling should be addressed first. If the client perceives value to the service provided, they will be likely to provide follow-up care. While the bp, blood glucose, and vision are concerning, the client's stated concern should be addressed first. The nurse is preparing discharge resources for a client being discharged to the homeless shelter. When looking at the discharge medication reconciliation form, the nurse determines there is a need for follow-up if which medication was prescribed? 1. Glipizide 2. Lisinopril 3. Metformin 4. Beclomethasone 1. Glipizide Rationale: Glipizide is an oral hypoglycemic medication and is classified as a sulfonylurea. A major side effect of this medication is hypoglycemia, which is a safety risk to the homeless population. Lisinopril is an angiotensin-converting enzyme inhibitor. Although there are side effects that should be included in discharge instructions, there is less of a threat to safety with this medication and the benefits to it are important. Metformin is an oral biguanide and is used for type 2 diabetes mellitus. Hypoglycemia is less of a concern with this medication compared with other oral hypoglycemics. Beclomethasone is an inhaled corticosteroid used for obstructive lung disease, and although there are side effects the client should know about, there is not a particular safety risk associated with this medication for the homeless person. The nurse is completing the admission assessment for a client who is intellectually disabled. Which part of the client encounter may require more time to complete? 1. the history 2. the physical assessment 3. the nursing plan of care 4. the readmission risk assessment 1. the history Rationale: intellectually disabled clients tend to be poor historians, and it may take more time to ask questions in different ways when collecting the history data. The nurse working in a correctional facility is caring for a new prisoner. The client asks about health risks associated with living in a prison. How should the nurse respond? 1. "health care is very limited in the prison setting" 2. "living in a prison isn't different than living at home" 3. "living in a prison can predispose a person to different health conditions" 4. "living in a prison is similar to living in a condominium complex or dorm" 3. "living in a prison can predispose a person to different health conditions" Rationale: the environment of a prison can predispose a person to different health conditions. Option 1 does not address the client's question and options 2 and 4 convey incorrect information. A nurse working in a community outreach program for foster children plans care knowing that which health conditions are common in this population? Select all that apply: 1. asthma 2. claustrophobia 3. sleep problems 4. bipolar disorder 5. aggressive behavior 6. ADHD 3, 4, 5, 6 Rationale: foster children are at risk for a variety of health conditions later in life, including ADHD, aggressive behavior, anxiety disorder, bipolar disorder, depression, mood disorder, PTSD, reactive detachment disorder, sleep problems, prenatal drug and alcohol exposure, and personality disorder. Claustrophobia and asthma are not specifically associated with foster children. The nurse is caring for a female client in the ED who presents with a complaint of fatigue and SOB. Which physical assessment findings, if noted by the nurse, warrant a need for follow up? 1. reddened sclera of the eyes 2. dry flaking noted on the scalp 3. a reddish-purple mark on the neck 4. a scaly rash noted on the elbows and knees 3. a reddish-purple mark on the neck Rationale: The client should be screened for abuse. Battered women experience bruises, particularly around the eyes, red or purple marks on the neck, sprained or broken wrists, chronic fatigue, SOB, muscle tension, involuntary shaking, changes in eating and sleeping, sexual dysfunction, and fertility issues. Mental health issues can also arise including PTSD, nightmares, anxiety, uncontrollable thoughts, depression, anxiety, low self-esteem, and alcohol and drug abuse. Reddened sclera, a dry rash on the elbows, and flaking of the scalp do not indicate abuse. The nurse planning care for a military veteran should prioritize nursing interventions targeted at managing which condition, if present, that commonly occurs in this population? 1. hypertension 2. hyperlipidemia 3. substance abuse disorder 4. PTSD 4. PTSD Rationale: PTSD is extremely common in this population. Identifying and treating mental health disorders assists in lowering the suicide risk. Treatment of comorbid conditions such as PTSD may also help address any substance abuse disorder. Use of screening tools in identifying substance use disorder is helpful. Treatment of PTSD includes exposure therapy, psychotherapy, and family/group therapy. Hypertension and hyperlipidemia are important but not priority; the risk of suicide and other safety concerns associated with PTSD are the priority for this population. The nurse caring for a refugee considers which health care need a priority for this client? 1. access to housing 2. access to clean water 3. access to transportation 4. access to mental health care services 4. access to mental health care services Rationale: Mental health problems are the primary issue for this population as a result of tortuous events. While all the other options are important, they do not address the specific needs of this special population. Which action by the nurse will best facilitate adherence to the treatment regimen for a client with a chronic illness? 1. arranging for home health care 2. focusing on managing a single illness at a time 3. communicating with one provider only to avoid confusion for the client 4. allowing the client to teach a support person about their treatment regimen 1. arranging for home health care Rationale: Nursing follow-up visits are important in promoting health for individuals with chronic illness, therefore, arranging for home health care is an important strategy. The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report? 1. The client fell out of bed. 2. The client climbed over the side rails. 3. The client was found lying on the floor. 4. The client became restless and tried to get out of bed. 3. the client was found lying on the floor Rationale: The occurrence report should contain a factual description of the occurrence, any injuries experienced by those involved, and the outcome of the situation. The other options are interpretations of the situation, not facts. A client is brought to the ED by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? 1. obtain a court order for the surgical procedure 2. ask the EMS team to sign the informed consent 3. transport the victim to the operating room for surgery 4. call the police to identify the client and notify the family 3. transport the victim to the operating room for surgery Rationale: two situations where informed consent is not needed are when an emergency is present and delaying treatment in order to get informed consent would result in injury or death to the client, or when the client waives the right to get informed consent. A nurse has just assisted a client back to bed after a fall. The nurse and primary healthcare provider have assessed the client and have determined that the client is not injured. After completing the occurrence report, the nurse should implement which action next? 1. reassess the client 2. conduct a staff meeting to describe the fall 3. contact the nursing supervisor to update info regarding the fall 4. document in the nurse's notes that an occurrence report was completed 1. reassess the client Rationale: after a client's fall, the nurse must frequently reassess the client. Their fall should be treated as private information and given on a "need to know" basis. The nurse does not need to put the completion of the occurrence report in the nurse's notes. A nurse arrives at work and is told to float to the ICU for the day because they're understaffed and need additional nurses to care for clients. The nurse has never worked in the ICU. The nurse should take which best action? 1. refuse to float to the ICU because of lack of unit orientation 2. clarify the ICU client assignment with the team leader to ensure it's a safe assignment 3. ask the nursing supervisor to review the hospital policy on floating 4. submit a written protest to nursing administration, and then call the hospital lawyer 2. clarify the ICU client assignment with the team leader to ensure it's a safe assignment Rationale: Legally, the nurse cannot refuse to float unless a union contract guarantees that nurses can only work in a specified area or the nurse can prove the lack of knowledge for the performed tasks. The nurse who works on the night shift enters the medication room and finds a coworker with a tourniquet wrapped around her upper arm. The coworker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse? 1. call security 2. call police 3. call the nursing supervisor 4. lock the coworker in the medication room until help is obtained 3. call the nursing supervisor Rationale: the nurse practice act requires reporting impaired nurses. The nurse should report it to the nursing supervisor. A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client? 1. "I will sign as a witness to your signature" 2. "you will need to find a witness on your own" 3. "whoever is available at the time will sign as a witness for you" 4. "I will call the nursing supervisor to seek assistance regarding your request" 4. "I will call the nursing supervisor to seek assistance regarding your request" Rationale: Living wills are required to be in writing and signed by the client, and their signature must be witnessed or notarized. Laws regarding living wills vary by state to state, and many states inhibit any employee from being a witness. The nurse has made an error in documentation of dose administered of an opioid pain medication in the client's record. The nurse draws 1 mg from the vial and another RN witnesses wasting of the remaining 1 mg. When scanning the medication, the nurse entered into the MAR that 2 mg of hydromorphone was administered instead of the actual dose administered, which was 1 mg. The nurse should take which actions to correct the MAR? Select all that apply: 1. complete and file an occurrence report 2. right-click on the entry and modify it to reflect the correct information 3. document the correct information and end with the nurse'e signature and title 4. obtain a cosignature from the RN who witnessed the waste of the remaining 1 mg 5. document in a nurse's note in the client's record detailing the corrected information. 2, 3, 4, 5 Rationale: Electronic health records will have a time date stamp that indicates an amendment has been entered. If the nurse makes an error, they should follow agency protocols to correct the error. In the MAR the nurse can right click on the entry and modify it to correct it. Since this is an opioid medication, the nurse should obtain a cosignature from the RN who witnessed the wasting of the excess medication. A nurse's note should be used to detail the event and the corrections made, and the nurse's name and title will be stamped on the entry in the record. An occurrence report is not needed in this situation. Which identifies accurate nursing documentation notations? Select all that apply: 1. The client slept through the night 2. Abdominal wound dressing is dry and intact without drainage 3. The client seemed angry when awakened for vital sign measurement 4. The client appears to become anxious when it is time for respiratory treatments 5. The client's left lower medial leg wound is 3cm in length without redness, drainage, or edema 1, 2, 5 Rationale: Factual documentation has descriptive, objective information about what the nurse sees, feels, hears, or smells. Inferences and vague terms are not acceptable because its an opinion/not factual. A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of this client right? 1. performing a procedure without consent 2. threatening to give a client medication 3. telling the client that he or she cannot leave the hospital 4. observing care provided to the client without the client's permission 4. observing care provided to the client without the client's permission Rationale: invasion of privacy occurs with unreasonable intrusion into an individual's private affairs. Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive personnel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. Which legal tort has the UAP violated? 1. Libel 2. Slander 3. Assault 4. Negligence 2. Slander Rationale: Defamation is a false communication or a careless disregard for the truth that causes damage to someone's reputation either in writing (libel) or verbally (slander). An older woman is brought to the ED for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he gets home from work. Which is the most appropriate nursing response? 1. "Oh, really? I will discuss this situation with your son" 2. "Lets talk about ways you can manage your time to prevent this from happening" 3. "Do you have any friends who could help you out until you resolve these issues with your son?" 4. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay" 4. "As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay" Rationale: The nurse must report situations related to child or elder abuse, gunshot wounds and other criminal acts, and certain infectious diseases. The nurse calls the primary hc provider regarding a new medication prescription, because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the primary hc provider, and the medication is due to be administered. Which action should the nurse take? 1. contact the nursing supervisor 2. administer the dose prescribed 3. hold the medication until the primary hc provider can be contacted 4. administer the recommended does until the primary hc provider can be located 1. contact the nursing supervisor Rationale: If the primary care provider writes a prescription that requires clarification, it is the nurse's responsibility to contact them. If that is not able to happen, the nurse should contact the nursing supervisor or nurse manager for further clarification as to what the next step should be. The nurse employed in a hospital is waiting to receive a report from the lab from the fax machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photo. Which is the most appropriate nursing action? 1. call the police 2. cut up the photo and throw it away 3. call the nursing supervisor and report the occurrence 4. call the lab and ask for the name of the individual who sent the photo 3. call the nursing supervisor and report the occurrence The nurse is assigned to care for 4 client. In planning client rounds, which client should the nurse assess first? 1. a post-op client preparing for discharge with a new medication 2. a client requiring daily dressing changes of a recent surgical incision 3. a client scheduled for a chest x-ray after an insertion of a nasogastric tube 4. a client with asthma who requested a breathing treatment during the previous shift 4. a client with asthma who requested a breathing treatment during the previous shift Rationale: airway is always the highest priority, and since the client had difficulty breathing during the previous shift they should assess them first. The nurse employed in an ED is assigned to triage clients coming to the ED for treatment on the evening shift. The nurse should assign priority to which client? 1. a client complaining of muscle aches, headache, and a history of seizures 2. a client who twisted her ankle when rollerblading and is requesting medication for pain 3. a client with a minor laceration on the index finger sustained while cutting an eggplant 4. a client with chest pain who states that he just ate pizza that was made with a very spicy sauce 4. a client with chest pain who states that he just ate pizza that was made with a very spicy sauce Rationale: clients with trauma, chest pain, severe respiratory distress, cardiac arrest, limb amputation, acute neurological defects, or who have sustained chemical splashes to the eyes are classified as emergent and are priority. A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the hc facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice? 1. each staff member is assigned a specific task for a group of clients 2. a staff member is assigned to determine the client's needs at home and begin discharge planning 3. a single RN is responsible for providing care to a group of 6 clients with the help of assistive personnel 4. an RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients 4. an RN leads 2 licensed practical nurses (LPNs) and 3 APs in providing care to a group of 12 clients Rationale: in team nursing, nursing personnel are led by a RN leader in providing care to a group of clients. The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first? 1. a client who is ambulatory demonstrating steady gait 2. a post-op client who has just received an opioid pain med 3. a client scheduled for PT for their first crutch-walking session 4. a client with a WBC count of 14,000 mm and a temp of 38.4 C 4. a client with a WBC count of 14,000 and a temp of 38.4 C Rationale: The nurse should plan to care for the client who has an elevated WBC count and a fever first because their needs are the priority. The nurse is giving a bed bath to an assigned client when an AP enters the client's room and tells the nurse another assigned client is in pain and needs pain meds. Which is the most appropriate nursing action? 1. finish the bed bath and then administer the pain med to the other client 2. ask the AP to find out when the last pain med was given to the client 3. ask the AP to tell the client in pain the med will be administered as soon as the bed bath is done 4. cover the client, raise the side rails, tell the client you'll return soon, and give the pain med to the other client 4. cover the client, raise the side rails, tell the client you'll return soon, and give the pain med to the other client Rationale: the nurse should provide safety to the client receiving the bed bath and prepare to give the pain med. The nurse manager has implemented a change in the method of the nursing delivery system from functional to team nursing. An AP is resistive to the change and is not taking an active part to facilitate the process of change. Which is the best approach in dealing with the AP? 1. Ignore the resistance 2. exert coercion on the AP 3. provide a positive reward system for the AP 4. confront the AP to encourage verbalization of feelings regarding the change 4. confront the AP to encourage verbalization of feelings regarding the change Rationale: confrontation is an important strategy to meet resistance head-on. The RN is planning client assignments for the day. Which is the most appropriate assignment for an AP? 1. a client requiring a colostomy irrigation 2. a client receiving continuous tube feedings 3. a client who requires urine specimen collections 4. a client with difficulty swallowing food and fluids 3. a client who requires urine specimen collections Rationale: The AP is skilled in the procedure of a urine specimen collection. Colostomy irrigations and tube feedings are not performed by APs because they're invasive procedures, and the client with difficulty swallowing is at risk for aspiration. The nurse manager is discussing the facility protocol in the event of a tornado with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply: 1. open doors to client rooms 2. move beds away from windows 3. close window shades and curtains 4. place blankets over client confined to beds 5. relocate ambulatory clients from the hallways back into their rooms 2, 3, 4 The nurse employed in a LTC facility is planning assignments for the clients in a nursing unit. The nurse needs to assign 4 clients and has a LPN and 3 APs on a nursing team. Which client would the nurse most appropriately assign to the LPN? 1. a client who requires a bed bath 2. an older client requiring frequent ambulation 3. a client who needs hourly vital sign measurements 4. a client requiring abdominal wound irrigations and dressing changes every 3 hours 4. a client requiring abdominal wound irrigations and dressing changes every 3 hours Rationale: giving a bed bath, assisting with frequent ambulation, and taking vitals can be done by an AP. The LPN is trained in wound irrigations and dressing changes so this is an appropriate assignment for them. The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply: 1. the acuity level of the clients 2. specific responses from the staff 3. the clustering of the rooms on the unit 4. the number of anticipated client discharges 5. client needs and worker needs and abilities 1, 5 Rationale: staff requests, convenience in clustering of rooms, and anticipated changes in unit census are not specific guidelines to use when delegating and planning assignments. The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? 1. weight loss and dry skin 2. flat neck and hand veins and decreased urinary output 3. an increase in bp and increased respirations 4. weakness and decreased central venous pressure (CVP) 3. an increase in bp and increased respirations Rationale: Assessment findings associated with fluid volume excess are cough, dyspnea, crackles, tachypnea, tachycardia, elevated bp, bounding pulse, elevated CVP, weight gain, edema, neck and hand vein distention, altered LOC, and decreased hematocrit. The nurse reviews a client's record and determines that the client is at risk for developing a K+ deficit if which situation is documented? 1. sustained tissue damage 2. requires nasogastric suction 3. has a history of addison's disease 4. uric acid level of 9.4 mg/dl (557 mcmol/L) 2. requires nasogastric suction Rationale: the normal serum K+ level is 3.5 to 5.0. K+-rich GI fluids are lost through GI suction, placing the client at risk for hypokalemia. The client with tissue damage or Addison's disease and the client with hyperuricemia are at risk for hyperkalemia. The nurse reviews a client's electrolyte lab report and notes the client's K+ level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the ECG as a result of the lab value? Select all that apply: 1. U waves 2. absent P waves 3. inverted T waves 4. depressed ST segment 5. widened QRS complex 1, 3, 4 Rationale: A serum K+ level lower than 3.5 indicates hypokalemia. K+ deficit is an electrolyte imbalance that can be potentially life-threatening. ECG changes include shallow, flat, or inverted T waves, ST segment depression, and prominent U waves. Absent P waves are not present in hypokalemia but may be noted in a client with atrial fibrillation, junctional rhythms, or ventricular rhythms. A widened QRS complex may be noted in hyperkalemia and hypermagnesemia. Potassium chloride intravenously is prescribed for a client with HF experiencing hypokalemia. Which actions should the nurse take to plan for preparation and administration of the K+? Select all that apply: 1. obtain an IV infusion pump 2. monitor urine output during administration 3. prepare the medication for bolus administration 4. monitor the IV site for signs of infiltration or phlebitis 5. ensure the medication is diluted in the appropriate volume of fluid 6. ensure the bag is labeled so it reads the volume of K+ in the solution 1, 2, 4, 5, 6 Rationale: potassium chloride administered IV must always be diluted in IV fluid and infused via an infusion pump. Potassium chloride is never given by bolus (IV push). The IV bag containing the potassium chloride should always be labeled with the amount of potassium it contains. The IV site is monitored closely, because it's irritating to the veins and there's a risk of phlebitis. In addition, the nurse should monitor for infiltration. The nurse monitors for urine output during administration and should contact the doctor if urinary output is less than 30 mL/hour. [Show Less]
- Exam
- $20.45
- 0
- 220
Saunders Comprehensive Review for the NCLEX-RN Exam Pre-op, Intra-op, post-op
A nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical s... [Show More] ite? 1. Red, hard skin 2. Serous drainage 3. Purulent drainage 4. Warm, tender skin 2. Serous drainage Rationale: Serous drainage is an expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique or a contaminated wound before surgical exploration; existing client conditions such as diabetes mellitus or immunocompromise may place the client at risk. Test-taking strategy: Use the process of elimination, noting the strategy words normal finding. Recalling the signs of a wound infection and noting these strategy words will direct you to option 2. Review the signs of a wound infection if you had difficulty with this question. When performing a surgical dressing change of a client's abdominal dressing, a nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse should do which of the following in the initial care of this wound? 1. Leave the incision open to the air to dry the area. 2. Irrigate the wound and apply a sterile dry dressing. 3. Apply a sterile dressing soaked with normal saline. 4. Apply a sterile dressing soaked in providone-iodine (Betadine). 3. Apply a sterile dressing soaked with normal saline. Rationale: Wound dehiscence is the separation of wound edges at the suture line. Signs and symptoms include increased drainage and the appearance of underlying tissues. Dehiscence usually occurs 6 to 8 days after surgery. The client should be instructed to remain quiet and avoid coughing or straining. The client should be positioned to prevent further stress on the wound (semi-Fowler's). Sterile dressings soaked with sterile normal saline should be used to cover the wound. The nurse must notify the physician after applying the initial dressing to the wound. Options 1, 2, and 4 are incorrect. Test-taking strategy: Use the process of elimination. Eliminate option 1 first because this action would dry the wound and also present a risk of infection to the underlying tissues. Eliminate options 2 and 4 next because a dry dressing and a dressing soaked with providone-iodine will irritate the exposed body tissues. Review initial nursing care when dehiscence or evisceration occurs if you had difficulty with this question. A nurse is monitoring the status of a postoperative client. The nurse would become most concerned with which of the following signs that could indicate an evolving complication? 1. Increasing restlessness 2. A negative Homans' sign 3. Hypoactive bowel sounds in all four quadrants 4. Blood pressure of 110/70 mm Hg and a pulse of 86 beats/min 1. Increasing restlessness Rationale: Increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication, such as hemorrhage, shock, or pulmonary embolism. A blood pressure of 110/70 mm Hg with a pulse of 86 beats/minute is within normal limits. Hypoactive bowel sounds heard in all four quadrants are a normal occurrence, as is a negative Homans' sign (A positive Homans' sign may indicate thrombophlebitis). Test-Taking Strategy: Use the process of elimination and note the strategic word, "most". Focus on the subject , "a manifestation of an evolving complication". Eliminate each of the incorrect options because they are comparable or alike and are normal expected findings. If you had difficulty with this question, review the normal expected postoperative findings and the signs and symptoms of postoperative complications. A nurse is reviewing a physician's order sheet for a preoperative client that states that the client must be NPO after midnight. The nurse would telephone the physician to clarify whether which of the following medications should be given to the client and not withheld? 1. Ferrous sulfate 2. Prednisone (Deltasone) 3. Cycloenzaprine (Flexeril) 4. Conjugated estrogen (Premarin) 2. Prednisone (Deltasone) Rationale: Prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Cyclobenzaprine (Flexeril) is a skeletal muscle relaxant. Conjugated estrogen (Premarin) is an estrogen used for hormone replacement therapy in postmenopausal women. These last three medications may be withheld before surgery without undue effects on the client. Test-Taking Strategy: Use the process of elimination and knowledge about medications that may have special implications for the surgical client. Focus on the subject, the medication that should be administered in the preoperative period. Remember that when stress is severe, corticosteroids are essential to life. Review the effects of corticosteroids if you had difficulty with this question. A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which of the following laboratory results should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? 1. Sodium, 141 mEq/L 2. Hemoglobin, 8.0 g/dL 3. Platelets, 210,000/mm3 4. Serum creatinine, 0.8 mg/dL 2. Hemoglobin, 8.0 g/dL Rationale: Routine screening tests include a complete blood count, serum electrolyte analysis, coagulation studies, and a serum creatinine test. The complete blood count includes the hemoglobin analysis. All these values are within normal range except for hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon. Test-Taking Strategy: Focus on the subject , an abnormal laboratory result that needs to be reported. Use knowledge of the normal laboratory values to assist in answering correctly. The hemoglobin value is the only incorrect laboratory finding. Review these laboratory values if you had difficulty answering this question. [Show Less]
- Exam
- $12.95
- 0
- 103
Saunders Comprehensive Review for the NCLEX: Ch 69 Complex Care latest update 2022
856. A client had a 100 mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of... [Show More] a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous bag (IV) has 400 mL remaining. The nurse should take which action FIRST? 1. Slow the IV infusion 2. Sit the client up in bed 3. Remove the IV catheter 4. Call the primary health care provider (PHCP) Answer: 1 Rationale: the client's symptoms are compatible with circulatory overload. This may be verified by noting that 600mL has been infused in the course of 45 minutes. The first action of the nurse is to slow the infusion. Other actions may be followed in rapid sequence. The nurse may elevate the head of the bed to aid in the client's breathing if necessary. The nurse also notifies the PCHP. the IV catheter is not removed; it may be needed for the administration of medications to resolve the complication. 857. Packed red blood cells have been prescribed for a female client with anemia who has a hemoglobin level of 7.6 g/dL (76 mol/L) and a hematocrit level of 30% (0.30). The nurse takes the client's temperature before the blood transfusion and records 100.6 degrees Fahrenheit (38.1 degrees Celsius) orally. Which action should the nurse take? 1. Begin the transfusion as prescribed 2. Administer an antihistamine and begin the transfusion 3. Administer 2 tablets of acetaminophen 4. Delay hanging the blood and notify the primary health care provider (PHCP) Answer: 4 Rationale: If the client has a temperature higher than 100 degrees F, the unit of blood should not be hung until the PHCP is notified and has the opportunity to give further instructions. The PHCP will likely prescribe that the blood be administered regardless of the temperature or may instruct the nurse to administer prescribed acetaminophen and wait until the temperature has decreased before administration, but the decision is not within the nurse's scope of practice to make. The nurse needs a PHCPs prescription to administer medication to the client. 858. The nurse is caring for a client experiencing acute lower gastrointestinal bleeding. In developing the plan of care, which priority problem should the nurse assign to this client? 1. deficient fluid volume related to acute blood loss 2. risk for aspiration related to acute bleeding in the GI tract 3. risk for infection related to acute disease process and medications 4. Imbalanced nutrition, less than body requirements, related to lack of nutrients and increased metabolism Answer 1 Rationale: the priority problem for the client with a cute gastrointestinal bleeding among these options is deficient fluid volume related to acute blood loss. This state can result in decreased cardiac output and hypovolemic shock. Although nutrition is a problem, fluid volume deficit is more of a priority. The client is at risk for aspiration and infection, but these are not actual problems at this point in time. 859. The nurse is assessing the functioning of a chest tube drainage system in a client with a chest injury who has just returned from the recovery room following a thoracotomy with wedge resection. SELECT ALL THAT APPLY 1. Excessive Bubbling in the water seal chamber 2. Vigorous bubbling in the suction control chamber 3. Drainage system maintained below the client's chest 4. 50mL of drainage in the drainage collection chamber 5. Occlusive dressing in place over the chest tube insertion site 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation Answer: 3,4,5,6 Rationale: the bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure; it may occur during exhalation, coughing, or sneezing.Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube of water in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has re-expanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client retuning to the nursing unit from the recovery room. Drainage that is more than 70 to 100 mL/hr is considered excessive and requires notification of the surgeon. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural system 860. A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? SELECT ALL THAT APPLY 1. Restrict fluids 2.Assess for airway patency 3.Administer oxygen as prescribed 4.Place a cooling blanket on the client 5.Elevate extremities if no fractures are present 6.Prepare to give oral pain medication as prescribed Answer: 2,3,5 Rationale: The primary goal for a burn injury is to maintain a patent airway, administer IV fluids to prevent hypovolemic shock and preserve vital organ functioning. Therefore, the priority actions are to assess for airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. An IV line should be obtained and fluid resuscitation started. The extremities are elevated tp assist in preventing shock and decrease fluid moving to the extremities, especially in the burn-injured extremities. The client is kept warm, because the loss of skin integrity causes heat loss. The client is placed on NPO (nothing by mouth) status because of the watered gastrointestinal function that occurs as a result of a burn injury 861. A client is admitted to a hospital with a diagnosis of diabetic keto acidosis (DKA). The initial blood glucose level is 950 mg/dL (52.9 mol/L). A continous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 250 mg/dL (13.37 mml/L). The nurse would next prepare to administer which medication? 1. an ampule of 50% dextrose 2. NPH insulin subcutaneously 3. IV fluids containing dextrose 4. Phenytoin for the prevention of seizures Answer: 3 Rationale: emergency management of DKA focuses on correcting fluid and electrolyte imbalances and normalizing the serum glucose level. If the corrections occur too quickly, serious consequences, including hypoglycemia and cerebral edema can occur. During management of DKA, when the blood glucose level falls to 250-300 mg/dL, the infusion rate is reduced and a dextrose solution is added to maintain a blood glucose level of about 250 mg/dL or until the client recovers from ketosis. 862. The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of ARDS? 1. bilateral wheezing 2. inspiratory crackles 3. intercostal retractions 4. increased respiratory rate Answer: 4 Rationale: The earliest detectable sign of ARDS is an increased respiratory rate, which begins from 1 to 96 hours after the initial insult to the body. This is followed by dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles. 863. A client is admitted to the emergency department with chest pain that is consistent with myocardial infarction based on the elevated troponin levels. Heart sounds are normal. The nurse should alert the primary health care provider because the vital sign changes and client assessment are most consistent with which complication? Time: 11:00am. 11:15 am. 11:30 am. 11:45 am Pulse: 92 bpm. 96 bpm. 104 bpm. 118 bpm Resp: 24 breaths. 26 breaths. 28 breaths. 32 breaths per min. per min. per min. per min BP: 140/88 128/82 104/68 88/58 1. Cardiogenic shock 2. cardiac tamponade 3. pulmonary embolism 4. dissecting thoracic aortic aneurysm Answer: 1 Rationale: cardiogenic shock occurs with severe damage (more than 40%) to the left ventricle. Classic signs include hypotension, a paid pulse that becomes weaker; decreased urine output and cool, clammy skin. Respiratory rate increases as the body develops metabolic acidosis from shock. Cardiac tamponade is accompanied by distant, muffled heart sounds and prominent neck vessels. Pulmonary embolism presents suddenly with severe dyspnea accompanying the chest pain. Dissection aortic aneurysm usually are accompanied by back pain. 864. The nurse is caring for a client with chronic kidney disease on continuous replacement renal therapy (CRRT) without the use of a hemodialysis machine. The nurse determines that which parameters is most important in ensuring success of this treatment? 1. Mean arterial pressure (MAP) 2. Systolic blood pressure (SBP) 3. Diastolic blood pressure (DBP) 4. Central venous pressure (CVP) Answer: 1 Rationale: CRRT provides continuous ultrafiltration of extracellular fluid and clearance of urinary toxins over a period of 8 to 24 hours; it is used primarily for clients with AKI or critical ill patients with CKD who cannot tolerate hemodialysis. Water, electrolytes and other solutes are removed as the client's blood passes through a hemofilter. If CRRT does not require a hemodialysis machine, the client's MAP needs to be maintained above 60 mmHg and arterial and venous access sites are necessary. 865. The nurse is monitoring a client with a head injury for signs of increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1. increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure Answer: 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure Rationale:A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. respiratory irregularities may occur. 866. A client develops an anaphylactic reactions after receiving morphine. The nurse should plan to institute which actions? SATA 1. administer oxygen 2. quickly assess the clients respiratory status 3. document the event, interventions and client's response 4. keep the client supine regardless of the blood pressure readings 5. leave the client briefly to contact a primary health care provider 6. start an IV infusion of D5W and administer a 500 mL bolus Answer: 1,2,3 Rationale: an anaphylactic section requires immediate actions, starting with quickly assessing the client's respiratory status. Although the PHCP and the Rapid Response Team must be notified immediately, the nurse must stay with the client. Oxygen is administered and an IV normal saline is started and infused per PHCP prescription. Documentation of the event, actions taken, and client outcomes needs to be done. The head of the bed should be elevated if the client's blood pressure is normal. 867. A client in shock develops a central venous pressure of 2mmHg and a mean arterial pressure of 60 mmHg. Which prescribed intervention should the nurse implement first? 1. increase the rate of O2 flow 2.obtain arterial gas results 3. insert an indwelling urinary catheter 4. increase the rate of IV fluids Answer: 4 Rationale: the MAP and CVP are both low for this patient, indicating a state of shock. Shock is the result of inadequate perfusion. Fluid volume should be immediately restored first to provide adequate perfusion for the client in a shock state. 868. A client at risk for shock secondary to pneumonia develops restlessness and is agitated and confused. Urinary output has decreased and the blood pressure is 92/68. The nurse minimally suspects which stage of shock based on this data? 1.Stage 1 2.Stage 2 3.Stage 3 4.Stage 4 Answer: 2 Rationale: Stage 2 is characterized by cardiac output of less than 4 to 6 L per minute, systolic blood pressure less than 100 mmHg, decreased urinary output, confusion and cerebral perfusion pressure than is less than 70 mmHg 869. The nurse is caring for a client hospitalized for heart failure exacerbation and suspects the client may be entering a state of shock. The nurse knows that which intervention is the priority for this client? 1.Adminstration of digoxin 2.Administrations of whole blood 3.Administration of intravenous fluids 4.Administration of packed red blood cells Answer 1: Rationale: the client in this question is likely experiencing cariogenic shock secondary to heart failure exacerbation. It is important to note that if the shocks state is cardiogenic in nature, the infusion of volume-expanding fluids may result in pulmonary edema; therefore restoration of cardiac function is priority for this type of shock. Cardiotonic mediations such as digoxin, dopamine or norepinephrine may be administered to increase cardiac contractility and induce vasoconstriction. The other options may complicate the client's condition 870. Which clinical findings are consistent with sepsis diagnostic criteria? Select all that apply 1.Urine output 50 mL/hour 2.Hypoactive bowel sounds 3.Temperature of 102 degrees F 4.Heart rate of 96 beats/minute 5.Mean arterial pressure 65 mmHg 6.Systolic blood pressure 110 mmHg Answer: 3,4,5 Rationale: sepsis diagnostic criteria are as follows: fever (temp higher than 100.9 degrees F) hypothermia (core temp lower than (97 degrees F) tachycardia (HR above 90 bpm) tachypnea (RR above 22 breaths/minute) systolic BP less than or equal to 100 mmHg altered mental status positive fluid balance edema mottling of skin [Show Less]
- Exam
- $11.45
- 0
- 158
Purchase the bundle to get the full access instantly
- 3 Million+ Study Documents
- 100% Money Back Guarantee
- Immediate Download Access
Add To Cart
Reviews 0
Bundle Details
$30.95
- Trusted by 800,000+ Students
- 24/7 Money Back Guarantee
- Download is directly available
200
0
Seller Details
