NCLEX PN Saunders Assessment Practice 4
(Answered)
caring for a patient with flu like symptoms
plenty of rest, increase intake of fluids, encourage client take antipyuretics to decrease
fever.
plan of action for the emergency department, in an event of internal fire.
direct ambulating clients to walk to a safe location, remove all clients from danger
before attempting to extinguish the fire, move bedridden clients away from the fire are
by use of beds or stretchers.
pregnant client receiving MAGNESIUM SULFATE for management of
PREECLAMPSIA. client is experiencing toxicity from medication
respirations of 10 bpm
toxicity= cns depressant effects, respirations lower than 12 per minute, a LOSS of deep
tendon reflexes, a sudden drop in fetal HR or maternal HR and BP.
protienuria is noted 3+ in preeclampsia
tb skin test administered to an individual with HIV. 72 hrs later your document should
show POSITIVE results with
area of induration at the test site measuring 7mm.
normally area of induration greater than 15 mm is considered positive in low-risk.
5mm + in individuals with HIV infection is considered positive.
An unconscious client, bleeding profusely, is brought to the emergency department after
a serious accident. Surgery is required immediately to save the client's life. With regard
to informed consent for the surgical procedure, which is the best action?
Transport the client to the operating department immediately, as required by the health
care provider, without obtaining an informed consent.
Rationale: Generally there are only two instances in which the informed consent of an
adult client is not needed. One instance is when an emergency is present and delaying
treatment for the purpose of obtaining informed consent would result in injury or death
to the client. The second instance is when the client waives the right to give informed
consent.
A client is in the first stage of labor. Which nursing actions are implemented in the first
stage of labor? Select all that apply.
Encourage frequent urination, Continue maternal and fetal assessments, Review
breathing and relaxation techniques.
Rationale: Failure to empty the urinary bladder can lead to rupture of the urinary
bladder, or it can prevent effective contractions, thereby restricting the progress of
labor... client should be allowed lollipops to hold and suck on between contractions for
carbohydrate and fluid intake
The client has a PRN prescription for loperamide hydrochloride (Imodium). The nurse
understands that this medication is used for which condition?
,An episode of diarrhea
Rationale:
Loperamide is an antidiarrheal agent. It is used to manage acute and also chronic
diarrhea in conditions such as inflammatory bowel disease. Loperamide also can be
used to reduce the volume of drainage from an ileostomy. It is not used for the
conditions in options 1, 2, and 4.
A client who has undergone a subtotal gastrectomy is being prepared for discharge.
Which items concerning ongoing self-management should the nurse reinforce to the
client? Select all that apply
Eat smaller and more frequent meals.
Drink fluids between meals not with them.
Rationale:
Following gastric surgery, the client should eat smaller, more frequent meals to facilitate
digestion. Fluids should be taken between meals not with them to avoid dumping
syndrome.
The nurse has reinforced instructions to a client who is scheduled for a cataract
extraction. Which statement by the client indicates a need for further teaching?
"No eating or drinking for at least 18 hours before the surgery."
Rationale:
The client scheduled for cataract surgery should be instructed that oral intake may be
restricted for 6 to 12 hours preoperatively. It is not necessary that the client take nothing
per mouth (NPO) for 18 hours before surgery.
A client is diagnosed with hyperparathyroidism. The nurse teaching the client about
dietary alterations to manage the disorder tells the client to limit which food in the diet?
Ice cream
Rationale:
The client with hyperparathyroidism is likely to have elevated calcium levels. This client
should reduce intake of dairy products such as milk, cheese, ice cream, or yogurt.
Apples, bananas, chicken, oatmeal, and pasta are low-calcium foods.
A 6-year-old child with leukemia is hospitalized and is receiving combination
chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse
prepares to implement protective isolation procedures. Which interventions should the
nurse initiate? Select all that apply.
Place the child on a low-bacteria diet, Change dressings using sterile technique,Perform
meticulous hand washing before caring for the child.
Rationale:
For the hospitalized neutropenic child, flowers or plants should not be kept in the room
because standing water and damp soil harbor Aspergillus and Pseudomonas, to which
these children are very susceptible. Fruits and vegetables not peeled before being
eaten harbor molds and should be avoided until the white blood cell count rises. The
child is placed on a low-bacteria diet. Dressings are always changed with sterile
technique. Not all visitors need to be restricted, but anyone who is ill should not be
allowed in the child's room. Meticulous hand washing is required before caring for the
child. In addition, gloves, a mask, and a gown are worn (per agency policy).
Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before
the administration of methylergonovine, the nurse should check which priority item?
, blood pressure
Rationale:
Methylergonovine, which is an ergot alkaloid, is an agent that is used to prevent or
control postpartum hemorrhage by contracting the uterus. Methylergonovine causes
continuous uterine contractions and may elevate the blood pressure.
The nurse is monitoring a preterm labor client who is receiving magnesium sulfate
intravenously. The nurse should monitor for which adverse effects of this medication?
Select all that apply.
Flushing, Depressed respirations, Extreme muscle weakness
Rationale: Magnesium sulfate is a central nervous system depressant, and it relaxes
smooth muscle, including the uterus. It is used to stop preterm labor contractions, and it
is used for preeclamptic clients to prevent seizures. Adverse effects include flushing,
depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle
weakness, decreased urine output, pulmonary edema, and elevated serum magnesium
levels.
A pregnant client is receiving magnesium sulfate for the management of preeclampsia.
The nurse determines that the client is experiencing toxicity from the medication if which
is noted on data collection?
Respirations of 10 breaths per minute
Epidural analgesia is administered to a woman for pain relief after a cesarean birth. The
nurse assigned to care for the woman ensures that which medication is readily available
if respiratory depression occurs?
Naloxone (Narcan)
Rationale:
Opioids are used for epidural analgesia. An adverse effect of epidural analgesia is a
delayed respiratory depression. Naloxone (Narcan) is an opioid antagonist, which
reverses the effects of opioids and is given for respiratory depression.
Rho(D) immune globulin (RhoGAM) is prescribed for a woman after the delivery of a
newborn infant, and the nurse provides information to the woman about the purpose of
the medication. The nurse determines that the woman understands the purpose of the
medication if the woman states that it will protect her next baby from which condition?
Being affected by Rh incompatibility
Rationale:
Rh incompatibility can occur when an Rh-negative mother becomes sensitized to the Rh
antigen. Sensitization may develop when an Rh-negative woman becomes
A woman with preeclampsia is receiving magnesium sulfate. Which indicates to the
nurse that the magnesium sulfate therapy is effective?
Seizures do not occur.
Rationale:
For a client with preeclampsia, the goal of care is directed at preventing eclampsia
(seizures). Magnesium sulfate is an anticonvulsant rather than an antihypertensive
agent. Although a decrease in blood pressure may be noted initially, this effect is
usually transient.
Methylergonovine is prescribed for a client with postpartum hemorrhage. Before
administering the medication, the nurse should question administration of the
medication if which condition is documented in the client's medical history?
(Answered)
caring for a patient with flu like symptoms
plenty of rest, increase intake of fluids, encourage client take antipyuretics to decrease
fever.
plan of action for the emergency department, in an event of internal fire.
direct ambulating clients to walk to a safe location, remove all clients from danger
before attempting to extinguish the fire, move bedridden clients away from the fire are
by use of beds or stretchers.
pregnant client receiving MAGNESIUM SULFATE for management of
PREECLAMPSIA. client is experiencing toxicity from medication
respirations of 10 bpm
toxicity= cns depressant effects, respirations lower than 12 per minute, a LOSS of deep
tendon reflexes, a sudden drop in fetal HR or maternal HR and BP.
protienuria is noted 3+ in preeclampsia
tb skin test administered to an individual with HIV. 72 hrs later your document should
show POSITIVE results with
area of induration at the test site measuring 7mm.
normally area of induration greater than 15 mm is considered positive in low-risk.
5mm + in individuals with HIV infection is considered positive.
An unconscious client, bleeding profusely, is brought to the emergency department after
a serious accident. Surgery is required immediately to save the client's life. With regard
to informed consent for the surgical procedure, which is the best action?
Transport the client to the operating department immediately, as required by the health
care provider, without obtaining an informed consent.
Rationale: Generally there are only two instances in which the informed consent of an
adult client is not needed. One instance is when an emergency is present and delaying
treatment for the purpose of obtaining informed consent would result in injury or death
to the client. The second instance is when the client waives the right to give informed
consent.
A client is in the first stage of labor. Which nursing actions are implemented in the first
stage of labor? Select all that apply.
Encourage frequent urination, Continue maternal and fetal assessments, Review
breathing and relaxation techniques.
Rationale: Failure to empty the urinary bladder can lead to rupture of the urinary
bladder, or it can prevent effective contractions, thereby restricting the progress of
labor... client should be allowed lollipops to hold and suck on between contractions for
carbohydrate and fluid intake
The client has a PRN prescription for loperamide hydrochloride (Imodium). The nurse
understands that this medication is used for which condition?
,An episode of diarrhea
Rationale:
Loperamide is an antidiarrheal agent. It is used to manage acute and also chronic
diarrhea in conditions such as inflammatory bowel disease. Loperamide also can be
used to reduce the volume of drainage from an ileostomy. It is not used for the
conditions in options 1, 2, and 4.
A client who has undergone a subtotal gastrectomy is being prepared for discharge.
Which items concerning ongoing self-management should the nurse reinforce to the
client? Select all that apply
Eat smaller and more frequent meals.
Drink fluids between meals not with them.
Rationale:
Following gastric surgery, the client should eat smaller, more frequent meals to facilitate
digestion. Fluids should be taken between meals not with them to avoid dumping
syndrome.
The nurse has reinforced instructions to a client who is scheduled for a cataract
extraction. Which statement by the client indicates a need for further teaching?
"No eating or drinking for at least 18 hours before the surgery."
Rationale:
The client scheduled for cataract surgery should be instructed that oral intake may be
restricted for 6 to 12 hours preoperatively. It is not necessary that the client take nothing
per mouth (NPO) for 18 hours before surgery.
A client is diagnosed with hyperparathyroidism. The nurse teaching the client about
dietary alterations to manage the disorder tells the client to limit which food in the diet?
Ice cream
Rationale:
The client with hyperparathyroidism is likely to have elevated calcium levels. This client
should reduce intake of dairy products such as milk, cheese, ice cream, or yogurt.
Apples, bananas, chicken, oatmeal, and pasta are low-calcium foods.
A 6-year-old child with leukemia is hospitalized and is receiving combination
chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse
prepares to implement protective isolation procedures. Which interventions should the
nurse initiate? Select all that apply.
Place the child on a low-bacteria diet, Change dressings using sterile technique,Perform
meticulous hand washing before caring for the child.
Rationale:
For the hospitalized neutropenic child, flowers or plants should not be kept in the room
because standing water and damp soil harbor Aspergillus and Pseudomonas, to which
these children are very susceptible. Fruits and vegetables not peeled before being
eaten harbor molds and should be avoided until the white blood cell count rises. The
child is placed on a low-bacteria diet. Dressings are always changed with sterile
technique. Not all visitors need to be restricted, but anyone who is ill should not be
allowed in the child's room. Meticulous hand washing is required before caring for the
child. In addition, gloves, a mask, and a gown are worn (per agency policy).
Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before
the administration of methylergonovine, the nurse should check which priority item?
, blood pressure
Rationale:
Methylergonovine, which is an ergot alkaloid, is an agent that is used to prevent or
control postpartum hemorrhage by contracting the uterus. Methylergonovine causes
continuous uterine contractions and may elevate the blood pressure.
The nurse is monitoring a preterm labor client who is receiving magnesium sulfate
intravenously. The nurse should monitor for which adverse effects of this medication?
Select all that apply.
Flushing, Depressed respirations, Extreme muscle weakness
Rationale: Magnesium sulfate is a central nervous system depressant, and it relaxes
smooth muscle, including the uterus. It is used to stop preterm labor contractions, and it
is used for preeclamptic clients to prevent seizures. Adverse effects include flushing,
depressed respirations, depressed deep tendon reflexes, hypotension, extreme muscle
weakness, decreased urine output, pulmonary edema, and elevated serum magnesium
levels.
A pregnant client is receiving magnesium sulfate for the management of preeclampsia.
The nurse determines that the client is experiencing toxicity from the medication if which
is noted on data collection?
Respirations of 10 breaths per minute
Epidural analgesia is administered to a woman for pain relief after a cesarean birth. The
nurse assigned to care for the woman ensures that which medication is readily available
if respiratory depression occurs?
Naloxone (Narcan)
Rationale:
Opioids are used for epidural analgesia. An adverse effect of epidural analgesia is a
delayed respiratory depression. Naloxone (Narcan) is an opioid antagonist, which
reverses the effects of opioids and is given for respiratory depression.
Rho(D) immune globulin (RhoGAM) is prescribed for a woman after the delivery of a
newborn infant, and the nurse provides information to the woman about the purpose of
the medication. The nurse determines that the woman understands the purpose of the
medication if the woman states that it will protect her next baby from which condition?
Being affected by Rh incompatibility
Rationale:
Rh incompatibility can occur when an Rh-negative mother becomes sensitized to the Rh
antigen. Sensitization may develop when an Rh-negative woman becomes
A woman with preeclampsia is receiving magnesium sulfate. Which indicates to the
nurse that the magnesium sulfate therapy is effective?
Seizures do not occur.
Rationale:
For a client with preeclampsia, the goal of care is directed at preventing eclampsia
(seizures). Magnesium sulfate is an anticonvulsant rather than an antihypertensive
agent. Although a decrease in blood pressure may be noted initially, this effect is
usually transient.
Methylergonovine is prescribed for a client with postpartum hemorrhage. Before
administering the medication, the nurse should question administration of the
medication if which condition is documented in the client's medical history?
