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Saunders Nclex Questions Latest 2024/2025
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Saunders Nclex Questions Latest 2024/2025
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Saunders Nclex Questions Latest2024/2025
The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this
method, which questions would the nurse ask the client? - ✔□✔□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 thismedication?
1-Blood urea
nitrogen2-
Cholesterol level
3- Potassium level
4- Creatinine level - ✔□✔□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'slaboratory 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. - ✔□✔□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). Thenurse should tell the client to avoid which food item?
1-
Grapes
2-
Spinach
3- Watermelon
4- Cottage cheese - ✔□✔□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 Koften 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 - ✔□✔□2-Air embolism
The signs and symptoms of air embolism include chest pain, dyspnea, hypoxia, anxiety,
tachycardia, andhypotension. 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 atthe IV insertion site. On assessment, the nurse detects coolness and swelling
at the site and notes that
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