Details of NURSING MED Surg 2 SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FIVE
1) A child with an autism spectrum disorder (ASD) is being admitted to the
... [Show More] hospital for diagnostic tests. Which room assignment is the most appropriate for the child?
Private room
2) The labor and delivery room nurse has just received reports on 4 clients. After reviewing the client data, the nurse should assess which client first?
A client who has just received an intravenous loading dose of magnesium sulfate to stop preterm labor
3) The nurse has developed a teaching plan for a client with hypertension regarding the administration of prescribed medications. What is the initial nursing action?
Assess the client's readiness to learn.
4) A client with cancer is receiving intravenous morphine sulfate for pain. When writing the plan of care for this client, the nurse should include which action as the priority action?
Monitor respiratory status.
5) The nurse is preparing to suction the airway of a client who has a tracheostomy tube and gathers the supplies needed for the procedure. In order of priority, which actions should the nurse take to perform this procedure? Arrange the actions in the order that they should be performed. All options must be used.
1) Place the client in a semi Fowler's position.
2) Turn on the suction device and set the regulator at 80 mm Hg.
3) Attach the suction tubing to the suction catheter.
4) Hyperoxygenate the client.
5) Insert the catheter into the tracheostomy until resistance is met, and then pull it back 1 cm.FROM 4143 TO 5142
6) Apply intermittent suction and slowly
withdraw the catheter while rotating it back and
forth.
6) The nurse notes blanching, coolness, and edema at a client's
peripheral intravenous (IV) site. Which nursing action is
the priority?
Remove the IV catheter.
7) A client has a prescription to begin an infusion of 1000 mL
of 5% dextrose in lactated Ringer's solution. The client has
an intravenous (IV) cannula inserted, and the nurse prepares
the solution and IV tubing. Arrange the actions in the order
that they should be performed. All options must be used.
1) Close the roller clamp on the IV tubing.
2) Spike the IV bag and half-fill the drip
chamber.
3) Open the roller clamp and fill the tubing.
4) Uncap the distal end of the tubing.
5) Attach the distal end of the tubing to the
client.
8) The nurse is caring for 4 pediatric clients. After receiving
reports from the night shift, which child should the nurse
assess first?
A 6-week-old infant admitted to the hospital
for decreased level of consciousness; shaken baby
syndrome is suspected
9) The nurse is assigned to 4 clients on a postoperative
surgical unit at a rural hospital. When prioritizing the
care, the nurse recognizes that the highest priority is
focused on which client?
The client with problems clearing the airway
related to abdominal incision pain
10)
The emergency department nurse is caring for a child
with suspected epiglottitis and has ensured that the child
has a patent airway. Which action is the next priority in
the care of this child?
Prepare the child for a chest radiograph.FROM 4143 TO 5142
11)
The nursing instructor asks the nursing student to
identify the priorities of care for an assigned client. The
nursing instructor determines that the nursing student
understands the client's needs when which statement is made?
"Actual or life-threatening concerns are the
priority."
12)
A hospitalized client with type 1 diabetes mellitus
received Humulin N and Humulin R insulin 2 hours ago (at
7:30 a.m.). The client calls the nurse and reports that he
is feeling hungry, shaky, and weak. The client ate breakfast
at 8 a.m. and is due to eat lunch at noon. Arrange the
actions that the nurse will take in the order that they
should be performed. All options must be used.
1) Check the client's blood glucose level.
2) Give the client ½ cup (118 mL) of fruit
juice to drink.
3) Take the client's vital signs.
4) Retest the blood glucose level.
5) Give the client a small snack of
carbohydrate and protein.
6) Document the client's complaints, actions
taken, and outcome.
13)
An emergency department nurse is preparing to receive 4
clients as a result of a motor vehicle crash. Which victim
should the nurse attend to first?
A 45-year-old man with chest pain, shortness
of breath, and diaphoresis
14)
The nurse is assigned to care for 4 clients. Which
client should the nurse assess first?
A client who has a peripheral (index finger)
oxygen saturation percentage of 85%
15)
The nurse has received her client assignment for the
day. Which client should the nurse care for first?
A client with postoperative pain reported at
7 out of 10, with 10 being the worstFROM 4143 TO 5142
16)
The nurse has received the client assignment for the
day. Which client should the nurse care for first?
The client admitted with the medical
diagnosis of neutropenia who is afebrile and is
complaining of pain with urination
17)
The nurse is the first responder at the scene of a 6-
car crash on a highway. Which victim should the nurse attend
to first?
18)
A victim experiencing dyspnea
The nurse in charge of a nursing unit is asked to
select the hospitalized clients who can be discharged so
that hospital beds can be made available for victims of a
community disaster. Which clients can be safely discharged?
Select all that apply.
A client with a Holter monitor
19)
A client receiving oral antibiotics
A client experiencing sinus rhythm
The nurse has received her client assignment for the
day. Which client should the nurse check first?
A client who has just returned from surgery
20)
The nurse is a responder at the scene of a building
collapse. Which victim should the nurse care for first?
Victim with an apparent chest wall defect and
asymmetrical chest wall movement
21)
The nurse manager of a medical-surgical unit is asked
to select the hospitalized clients who can be discharged so
that hospital beds can be made available for victims of a
community disaster. Which clients can be safely discharged?
Select all that apply.
Client postoperative day 1 after inguinal
herniorrhaphy, vital signs stable
Client 5 days after a myocardial infarction,
vital signs stable, absence of dysrhythmias
Client 1 day after cardiac catheterization,
normal study results, groin site free of hematomaFROM 4143 TO 5142
22)
The nurse is the first responder at the scene of an
accident in which a tire blowout caused a bus to roll over
several times. Which victim should the nurse attend to
first?
The confused 12-year-old with bright red
blood pulsing from an open fracture of the femur
23)
The nurse in charge of a nursing unit is asked to
select those hospitalized clients who can be discharged so
that hospital beds can be made available for victims of a
community disaster. Which clients can be safely discharged?
Select all that apply.
The client who 24 hours earlier gave birth to
her second child by caesarean delivery
The 48-hour postoperative client who has
undergone an ileostomy because of ulcerative
colitis
The 2-day postoperative client who has
undergone total knee replacement and is ambulating
with a walker
The 3-day postoperative client who has
undergone coronary artery bypass grafting and is
ready for rehabilitation
24)
The nurse has received her client assignment for the
day. Which client should the nurse care for first?
The 53-year-old client with heart failure who
has gained 4 pounds (1.8 kg) since yesterday and
is short of breath
25)
During morning report, the day nurse is given
information on the assigned clients. Which client should the
nurse assess first?
The 60-year-old client with leukemia who is
receiving the first round of chemotherapy, which
was started at 0630 and is scheduled to end at
noon
26)
The nurse determines that which client has the highest
priority needs?FROM 4143 TO 5142
The client who has an irregular apical pulse
of 120 beats per minute
27)
When planning care, which client should the nurse
assess first?
The client with a chest tube for a
pneumothorax
28)
The nurse assigned to 4 clients reviews client data at
the beginning of the shift. To which information should the
nurse give highest priority?
Pulse oximetry reading 89%
29)
A home health care nurse is planning client visits and
nursing activities for the day. The nurse begins the visits
at 9 a.m. All clients live within a 5-mile radius. In order
of priority, how the nurse should plan the assignments for
the day? Arrange the actions in the order that they should
be performed. All options must be used.
1) A client with diabetes mellitus who needs
a fasting blood glucose level drawn
2) The first dressing change for a client
requiring twice-daily dressing changes
3) A client being visited by the home health
aide at 1030
4) A client requiring supervision of a
dressing change
5) A client requiring an admission assessment
to home health care
6) The second dressing change for a client
requiring twice-daily dressing changes
30)
The nurse is monitoring a client receiving total
parenteral nutrition (TPN). The client suddenly develops
respiratory distress, dyspnea, and chest pain, and the nurse
suspects air embolism. In order of priority, how should the
nurse plan the actions to take? Arrange the actions in the
order that they should be performed. All options must be
used.
1) Clamp the intravenous (IV) catheter.FROM 4143 TO 5142
2) Position the client in a left
Trendelenburg's position.
31)
3) Contact the health care provider (HCP).
4) Administer oxygen.
5) Take the client's vital signs.
6) Document the occurrence.
A unit of packed red blood cells has been prescribed
for a client with low hemoglobin and hematocrit typing and
crossmatching. The nurse receives a telephone call from the
blood bank and is informed that the unit of blood is ready
for administration. In order of priority, how should the
nurse plan the actions to take? Arrange the actions in the
order that they should be performed. All options must be
used.
1) Verify the health care provider's (HCP's)
prescription for the blood transfusion.
2) Ensure that an informed consent has been
signed.
3) Insert an 18- or 19-gauge intravenous
catheter into the client.
bank.
5) Ask a licensed nurse to assist in
confirming vital signs and blood compatibility and
verifying client identity.
32)
6) Hang the bag of blood.
The nurse is monitoring a client in labor who is
receiving oxytocin and notes that the client is experiencing
hypertonic uterine contractions. In order of priority, how
should the nurse plan the actions to take? Arrange the
actions in the order that they should be performed. All
options must be used.
1) Stop the oxytocin infusion.
2) Reposition the client.
4) Obtain the unit of blood from the bloodFROM 4143 TO 5142
3) Administer oxygen by face mask at 8 to 10
L/min.
4) Perform a vaginal examination.
5) Check the client's blood pressure.
6) Administer medication as prescribed to
reduce uterine activity.
33)
After correctly completing the rights of medication
administration, performing hand hygiene, and ensuring the
correct position of the client, which steps should the nurse
take to administer medication via a volume control
container? Arrange the actions in the order that they should
be performed. All options must be used.
1) Fill volume control container with desired
amount of IV fluid by opening clamp between volume
control container and main IV bag.
2) Close the clamp and check to be sure that
clamp on air vent volume control container is
open.
3) Clean injection port on top of volume
control container with an antiseptic swab.
4) Remove needle cap and insert needleless
syringe tip through the port, and then inject the
medication. Label the volume control container
with the name of the medication, dosage, total
volume including diluents, and time of
administration.
5) Regulate intravenous (IV) infusion rate to
allow medication to infuse in the time recommended
by institutional policies.
6) Dispose of the syringe in puncture-proof
and leak-proof container. Discard supplies and
perform hand hygiene.
34)
The nurse from a medical unit is called to assist with
care for clients coming into the hospital emergency
department during an external disaster. Using principles of
triage during a disaster, the nurse should attend to the
client with which problem first?FROM 4143 TO 5142
35)
Bright red bleeding from a neck wound
The nurse is the first responder at the scene of a
train accident. Which victim should the nurse attend to
first?
36)
A victim experiencing airway obstruc
The nurse in charge of a nursing unit is asked to
select the hospitalized clients who can be discharged so
that hospital beds can be made available for victims of a
community disaster. Select the clients who can be safely
discharged. Select all that apply.
A client experiencing sinus rhythm
37)
A client receiving oral anticoagulants
A client with chronic atrial fibrillation
The nurse is the first responder at the scene of a
train accident. Which victim should the nurse attend to
first?
A young woman who appears dazed and confused
and is shivering
38)
Which client should the emergency department triage
nurse classify as emergent?
A client with crushing substernal pain who is
short of breath
39)
The nurse has performed a nonstress test on a pregnant
client and is reviewing the fetal monitor strip. How should
the nurse document this finding in the client's medical
record? Refer to Figure. (Figure from McKinney et al.
[2013], p. 310.)
View Figure
40)
Normal
The nursing instructor asks the nursing student about
the physiology related to the cessation of ovulation that
occurs during pregnancy. Which response, if made by the
student, indicates an understanding of this physiological
process? Select all that apply.FROM 4143 TO 5142
"Ovulation ceases during pregnancy because
the circulating levels of estrogen and
progesterone are high."
"The release of the follicle-stimulating
hormone and luteinizing hormone is inhibited by
adaptations related to pregnancy."
41)
The nurse encourages a pregnant client who is human
immunodeficiency virus (HIV) positive to immediately report
any early signs of vaginal discharge or perineal tenderness
to the health care provider. The client asks the nurse about
the importance of this action, and the nurse responds by
making which statement to the client?
"This is necessary to assist in identifying
potential infections that may need to be treated."
42)
A pregnant client who is anemic tells the nurse that
she is concerned about her infant's condition after
delivery. Which nursing response would best support the
client?
"The effects of anemia on your baby are
difficult to predict, but let's review your plan
of care to ensure you are providing the best
nutrition and growth potential."
43)
The client is being seen at 24 weeks' gestation at the
prenatal clinic. At her last routine visit, the fundus was
located at the umbilicus. Today, the fundus is measured and
found to be 23 cm. How should the nurse interpret this
finding?
44)
Fundus is at the appropriate level.
The nurse is performing a prenatal assessment on a
pregnant client. The nurse should plan to implement teaching
related to risk for abruptio placentae if which information
is obtained on assessment?
45)
The client has a history of hypertension.
During a prenatal visit, the nurse is explaining
dietary management to a client with preexisting diabetes
mellitus. The nurse determines that teaching has been
effective if the client makes which statement?FROM 4143 TO 5142 "Diet and insulin needs change during pregnancy." 46)
The nurse has provided home care instructions to a client with a history of cardiac disease who has just been told that she is pregnant. Which statement, if made by the client, indicates a need for further instruction?
"During the pregnancy, I need to avoid contact with other individuals as much as possible to prevent infection."
47)
The nurse assists a pregnant client with cardiac disease to identify resources to help her care for her 18month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources primarily for which reason?
Reduce excessive maternal stress and fatigue. 48)
The nurse is instructing a pregnant client on measures to increase iron in the diet. The nurse should tell the client to consume which food that contains the highest source of dietary iron?
Whole-grain cereal 49)
The nurse is reviewing a nutritional plan of care with a pregnant client and is identifying the food items highest in folic acid. The nurse determines that the client understands the foods that supply the highest amounts of folic acid if the client states that she will include which item in the daily diet?
Leafy green vegetables 50)
A pregnant client who is at 30 weeks' gestation comes to the clinic for a routine visit, and the nurse performs an assessment on her. Which observations made by the nurse during the assessment indicates a need for further teaching? Select all that apply.
The client is wearing knee-high nylon stockings.
The client is wearing sweatpants with snug elastic ankle bands. [Show Less]