Details of NURSING Med Surg 2 SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX LATEST 2021 COMPLETE
1)The nurse is providing discharge instructions to a Chinese
... [Show More] American client
regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. The nurse should implement which best action?
Answers-Continue with the instructions, verifying client understanding.
2) A critically ill Hispanic client tells the nurse through an interpreter that she is Roman Catholic and firmly believes in the rituals and traditions of the Catholic faith. Based on the client's statements, which actions by the nurse demonstrate cultural sensitivity and spiritual support? Select all that apply.(1,2,5)
Answers-Ensures that a close relative stays with the client
Makes a referral for a Catholic priest to visit the client Offers to provide a means for praying the rosary if the client wishes.
3) Which clients have a high risk of obesity and diabetes mellitus? Select all that apply.(1,2,4,5) Latino American Man Native American man Hispanic American man African American woman
4) The nurse is preparing a plan of care for a client, and is asking the client about religious preferences. The nurse considers the client's religious preferences as being characteristic of a Jehovah's Witness if which client statement is made? "I cannot have any food containing or prepared with blood."
5) The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior?
Answers-Reflecting a cultural value
6) When communicating with a client who speaks a different language, which best practice should the nurse implement?
Arrange for an interpreter to translate.7) The nurse educator is providing in-service education to the nursing
staff regarding transcultural nursing care; a staff member asks the
nurse educator to provide an example of the concept of acculturation.
The nurse educator should make which most appropriate response?
Answers-"A person who moves from China to the
United States (U.S.) and learns about and adapts ato the culture in
the U.S."
8)
An Asin American client is experiencing a fever. The
nurse plans care so that the client can self-treat the disorder using which method?
Foods considered to be yin
9)
Which meal tray should the nurse deliver to a client
of Orthodox Judaism faith who follows a kosher diet?
Sweet and sour chicken with rice and vegetables, mixed
fruit, juice.
10)
Which is the best nursing intervention regarding
complementary and alternative medicine?
Educating the client about therapies that he or she is using
or is interested in using
11)
An antihypertensive medication has been prescribed for a client
with hypertension. The client tells the clinic nurse that he would like to take an herbal
substance to help lower his blood pressure. The nurse should take which action?
Encourage the client to discuss the use of an herbal substance with
the health care provider (HCP).
12)
The nurse educator asks a student to list the 5
main categories of complementary and alternative medicine (CAM), developed by the
National Center for Complementary and Alternative Medicine. Which statement, if
made by the nursing student, indicates a need for further teaching regarding CAM
categories?
are a focus of CAM."
"Magnetic therapy and massage therapy13)
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?
The client was found lying on the floor.
14)
A client is brought to the emergency department 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?
Transport the victim to the operating room for surgery.
15)
The nurse has just assisted a client back to bed after a fall. The nurse and
health care provider have assessed the client and have determined that the client is
not injured. After completing the incident report, the nurse should implement which
action next?
Reassess the client.
16)
The nurse arrives at work and is told to report (float) to the intensive care unit
(ICU) for the day because the ICU is understaffed and needs additional nurses to care
for the clients. The nurse has never worked in the ICU. The nurse should take
which best action?
17)
Clarify with the team leader to make a safe ICU client assignment.
The nurse who works on the night shift enters the medication room and finds a
co-worker with a tourniquet wrapped around the upper arm. The co-worker 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?
Call the nursing supervisor.
18)
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
today 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?
"I will call the nursing supervisor to seek assistance regarding
your request."
18) The nurse has made an error in a narrative documentation of an
assessment finding on a client and obtains the client's record to correct the
error. The nurse should take which actions to correct the error? Select all
that apply. Document the correct information and end with the nurse's signature
and title.
Draw 1 line through the error, initialing and dating it.
19) Which identifies accurate nursing documentation notations? Select all that
apply.
The client slept through the night.
Abdominal wound dressing is dry and intact without drainage.
The client's left lower medial leg wound is 3 cm in length without
redness, drainage, or edema.
20)
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 a violation of this client right?
Observing care provided to the client without the client's permission
21)
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. The registered nurse should inform the UAP that
making this accusation has violated which legal tort?
Slander
22)
An 87-year-old woman is brought to the emergency department 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 arrives home from work.
Which is the most appropriate nursing response?
"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."
23)
The nurse calls the heath care provider (HCP) regarding a new medication
prescription because the dosage prescribed is higher than the recommended dosage.
The nurse is unable to locate the HCP, and the medication is due to be administered.
Which action should the nurse take?
Contact the nursing supervisor.24)
The nurse employed in a hospital is waiting to receive a report from the
laboratory via the facsimile (fax) machine. The fax machine activates and the nurse
expects the report, but instead receives a sexually oriented photograph. Which is
the most appropriate initial nursing action?
Call the nursing supervisor and report the incident.
25)
The nurse is assigned to care for four clients. In planning client rounds, which
client should the nurse assess first?
26)
The nurse employed in an emergency department is assigned to triage clients
coming to the emergency department for treatment on the evening shift. The nurse
should assign priority to which client?
27)
A nursing graduate is attending an agency orientation regarding the nursing
model of practice implemented in the health care 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?
28)
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?
29)
The nurse is giving a bed bath to an assigned client when an unlicensed
assistive personnel (UAP) enters the client's room and tells the nurse that another
assigned client is in pain and needs pain medication. Which is the most
appropriate nursing action?
30)
The nurse manager has implemented a change in the method of the nursing
delivery system from functional to team nursing. An unlicensed assistive personnel
(UAP) is resistant to the change and is not taking an active part in facilitating the
process of change. Which is the best approach in dealing with the UAP?
31)
The registered nurse is planning the client assignments for the day. Which is
32)
the most appropriate assignment for an unlicensed assistive personnel (UAP)?
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.
33)
The nurse employed in a long-term care facility is planning assignments for the
clients on a nursing unit. The nurse needs to assign four clients and has a licensed
practical (vocational) nurse and 3 unlicensed assistive personnel (UAPs) on a nursing
team. Which client would the nurse most appropriately assign to the licensed
practical (vocational) nurse?
34)
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.35)
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?
36)
The nurse is preparing to care for a client with a potassium deficit. The nurse
reviews the client's record and determines that the client is at risk for developing the
potassium deficit because of which situation?
37)
The nurse reviews a client's electrolyte laboratory report and notes that the
potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for
on the electrocardiogram (ECG) as a result of the laboratory value? Select all that
apply.
38)
Potassium chloride intravenously is prescribed for a client with hypokalemia.
Which actions should the nurse take to plan for preparation and administration of the
potassium? Select all that apply.
39)
The nurse provides instructions to a client with a low potassium level about the
foods that are high in potassium and tells the client to consume which foods? Select
all that apply.
40)
The nurse is reviewing laboratory results and notes that a client's serum
sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to
the health care provider (HCP) and the HCP prescribes dietary instructions based on
the sodium level. Which acceptable food items does the nurse instruct the client to
consume? Select all that apply.
41)
The nurse is assessing a client with a suspected diagnosis of hypocalcemia.
42)
Which clinical manifestation would the nurse expect to note in the client?
The nurse is caring for a client with hypocalcemia. Which patterns would the
nurse watch for on the electrocardiogram as a result of the laboratory value? Select
all that apply.
43)
The nurse reviews the electrolyte results of an assigned client and notes that
the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch
for on the cardiac monitor as a result of the laboratory value? Select all that apply.
44) Which client is at risk for the development of a sodium level at 130 mEq/L (130
mmol/L)?
45)
The nurse is caring for a client with heart failure who is receiving high doses of
a diuretic. On assessment, the nurse notes that the client has flat neck veins,
generalized muscle weakness, and diminished deep tendon reflexes. The nurse
suspects hyponatremia. What additional signs would the nurse expect to note in a
client with hyponatremia?46)
The nurse reviews a client's laboratory report and notes that the client's serum
phosphorus (phosphate) level is 1.8 mg/dL (0.45 mmol/L). Which condition most
likely caused this serum phosphorus level?
47)
The nurse is reading a health care provider's (HCP's) progress notes in the
client's record and reads that the HCP has documented "insensible fluid loss of
approximately 800 mL daily." The nurse makes a notation that insensible fluid loss
occurs through which type of excretion?
48)
The nurse is assigned to care for a group of clients. On review of the clients'
medical records, the nurse determines that which client is most likely at risk for a fluid
volume deficit?
49)
The nurse caring for a client who has been receiving intravenous (IV) diuretics
suspects that the client is experiencing a fluid volume deficit. Which assessment
finding would the nurse note in a client with this condition?
50)
On review of the clients' medical records, the nurse determines that which
client is at risk for fluid volume excess?
51) Which client is at risk for the development of a potassium level of 5.5mEq/L
(5.5 mmol/L)?
52)
The nurse reviews the arterial blood gas results of a client and notes the
following: pH 7.45, Paco2
of 30 mm Hg (30 mm Hg), and HCO3
– of 20 mEq/L (20 mmol/L).
The nurse analyzes these results as indicating which condition?
Respiratory alkalosis, compensated
53)
The nurse is caring for a client with a nasogastric tube that is attached to low
suction. The nurse monitors the client for manifestations of which disorder that the
client is at risk for?
Metabolic alkalosis
54)
A client with a 3-day history of nausea and vomiting presents to the emergency
department. The client is hypoventilating and has a respiratory rate of 10
breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart
rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the
results, expecting to note which finding?
An increased pH and an increased HCO3
–
55)
The nurse is caring for a client having respiratory distress related to an anxiety
attack. Recent arterial blood gas values are pH = 7.53, Pao2
Paco2 = 32 mmHg (32 mm Hg), and HCO3
= 72 mm Hg (72 mm Hg),
– = 28 mEq/L (28 mmol/L). Which conclusion
about the client should the nurse make?
The client is probably hyperventilating.
56)
The nurse is caring for a client with diabetic ketoacidosis and documents that
the client is experiencing Kussmaul's respirations. Which patterns did the nurse
observe? Select all that apply.
Respirations that are increased in rate
Respirations that are abnormally deep57) 58)
A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco2
is 90 mm Hg (90 mm Hg), and HCO3 – is
22 mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition? Respiratory acidosis without compensation
The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which
clinical manifestations associated with these ABG results? Select all that apply. Nausea Confusion Tachycardia Lightheadedness
59) The nurse reviews the blood gas results of a client with atelectasis. The nurse
analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings? pH 7.25, Paco2
50 mm Hg (50 mm Hg) 60) The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco2 of 30 mm Hg (30 mm Hg). The nurse has
determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? Potassium level of 3.0 mEq/L (3.0 mmol/L)
61) 62) The nurse is caring for a client with several broken ribs. The client is most
likely to experience what type of acid-base imbalance? Respiratory acidosis from inadequate ventilation
A client with atrial fibrillation who is receiving maintenance therapy of warfarin
sodium has a prothrombin time (PT) of 35 seconds and an international normalized ratio (INR) of 3.5. On the basis of these laboratory values, the nurse anticipates which prescription?
Holding the next dose of warfarin 63) A staff nurse is precepting a new graduate nurse and the new graduate is
assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management?
"I will be sure to cue in to any indicators that the client may be exaggerating their pain."
64) A client has been admitted to the hospital for urinary tract infection and
dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen (BUN) level drops to which value? 15 mg/dL (5.25 mmol/L) [Show Less]