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Saunders NCLEX questions and answers
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Saunders NCLEX questions and answers
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Saunders NCLEX questions andanswers
The |nurse |is |assessing |a |client's |postoperative |pain |using |the |PQRSTU |method. |Using |this
|method, |which |questions |would |the |nurse |ask |the |client? |- |ANSWERS✔✔ |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.
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 |- |ANSWERS✔✔ |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. |- |ANSWERS✔✔ |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 |- |ANSWERS✔✔ |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 |- |ANSWERS✔✔ |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? |- |ANSWERS✔✔ |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. |-
|ANSWERS✔✔ |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. |- |ANSWERS✔✔ |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.
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