Marty's Saunders NCLEX-RN
Remediation Questions And Answers
2023 A+
The nurse is assessing a client's postoperative pain using the PQRSTU method.
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this method, which questions would the nurse ask the client? Select all that apply.
"Where is the pain located?"
"Does pain medication help?"
"What does the pain feel like?"
"How does the pain affect you?"
"Do you have the pain when you sleep?"
"What makes your pain better or worse?" - Correct Answer-"Where is the pain located?"
"What does the pain feel like?"
"How does the pain affect you?"
"What makes your pain better or worse?"
Rationale:
The PQRSTU 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.
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?
The client is hemorrhaging.
The client needs to increase oral fluids.
The client is experiencing normal lochia discharge.
The client's health care provider needs to be notified of the finding. - Correct AnswerThe client is experiencing normal lochia discharge.
Rationale:
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 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?
Soft uterus
Abdominal pain
Nontender uterus
Painless vaginal bleeding - Correct Answer-Abdominal pain
Rationale:
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?
Contact the health care provider.
Place the mother in a Trendelenburg position.
Administer oxygen to the client by face mask.
Document the findings and continue to monitor fetal patterns. - Correct AnswerDocument the findings and continue to monitor fetal patterns.
Rationale:
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?
Urine tests negative for protein.
Fetal movements are more than four per hour.
Weight increases by more than 1 pound in a week.
The blood pressure reading is ranging between 122/80 and 132/88 mm Hg. - Correct
Answer-Weight increases by more than 1 pound in a week.
Rationale:
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?
Apply heat to the affected area.
Take acetaminophen (Tylenol) every 4 hours.
Self-administer calcium carbonate tablets three times daily.
Purchase a chewable antacid that contains calcium and take a tablet with each meal. -
Correct Answer-Apply heat to the affected area.
Rationale:
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 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?
"Why do you believe this?"
"Tell me more about the details of your belief."
"I hear what you are saying, but I don't share your belief."
"If you want a pass for tomorrow evening's movie, you'd better turn that light off this
minute." - Correct Answer-"I hear what you are saying, but I don't share your belief."
Rationale:
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.
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?
Try to convince the client of the need for the transfusion.
Speak to the family regarding the need for a blood transfusion.
Support the client's decision not to receive a blood transfusion.
Discuss with the client the results of the hemoglobin and hematocrit levels compared
with normal levels. - Correct Answer-Support the client's decision not to receive a blood
transfusion.
Rationale:
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 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?
Increase oral fluids.
Document the finding.
Notify the health care provider.
Place the infant supine in a side-lying position. - Correct Answer-Notify the health care
provider.
Rationale:
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.
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?
Lochial flow
Urine output
Temperature
Blood pressure - Correct Answer-Blood pressure
Rationale:
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?
Reinforce the dressing.
Document the findings.
Contact the health care provider.
Swab the drainage and send the sample to the laboratory for culture. - Correct AnswerContact the health care provider.
Rationale:
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?
Enteric
Contact
Droplet
Neutropenic - Correct Answer-Droplet
Rationale:
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?
Positive
Negative
Inconclusive
Definitive and requiring a repeat test - Correct Answer-Negative
Rationale:
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.
After a tonsillectomy, a child is brought to the pediatric unit. The nurse should
appropriately place the child in which position?
Prone
Supine
High Fowler's
Trendelenburg - Correct Answer-Prone
Rationale:
The child should be placed in a prone or side-lying position after tonsillectomy to
facilitate drainage. Options 2, 3, and 4 will not achieve this goal.
A nurse is monitoring a 7-year-old child who sustained a head injury in a motor vehicle
crash for signs of increased intracranial pressure (ICP). The nurse should assess the
child frequently for which early sign of increased ICP?
Nausea
Papilledema
Decerebrate posturing
Alterations in pupil size - Correct Answer-Nausea
Rationale:
Nausea is an early sign of increased ICP. Late signs of increased ICP include a
significant decrease in level of consciousness, Cushing's triad (increased systolic blood
pressure and widened pulse pressure, bradycardia, and irregular respirations), and
fixed and dilated pupils. Other late signs include decreased motor response to
command, decreased sensory response to painful stimuli, posturing, Cheyne-Stokes
respirations, and papilledema.
A nurse is preparing to administer digoxin (Lanoxin) to an infant with heart failure.
Before administering the medication, the nurse double-checks the dose, counts the
apical heart rate for 1 full minute, and obtains a rate of 88 beats/minute. Based on this
finding, which is the appropriate nursing action?
Withhold the medication.
Administer the medication.
Double-check the apical heart rate and administer the medication.
Check the blood pressure and respirations and administer the medication. - Correct
Answer-Withhold the medication.
Rationale:
Digoxin is a cardiac glycoside that is used to treat heart failure. A primary concern is
digoxin toxicity and the nurse needs to monitor closely for signs of toxicity and monitor
digoxin blood levels. The medication is effective within a narrow therapeutic digoxin
range (1.0 to 2.0 ng/mL). Safety in administration is achieved by double-checking the
dose and counting the apical heart rate for 1 full minute. If the heart rate is less than 100
beats/minute in an infant, the nurse would withhold the dose and contact the health care
provider. Therefore, options 2, 3, and 4 are incorrect actions; it would be harmful to
administer the medication.
The nurse is performing an admission assessment on a client who has been admitted to
the hospital with a diagnosis of suspected gastric ulcer. The nurse is asking the client
questions about pain. Which statement, if made by the client, would support the
diagnosis of gastric ulcer?
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