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NCLEX Saunders NCLEX 8th edition pt2
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NCLEX Saunders NCLEX 8th edition pt2 NCLEX Saunders NCLEX 8th edition pt2 NCLEX Saunders NCLEX 8th edition pt2
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NCLEX Saunders NCLEX 8th edition pt2The nurse reading the operative record of a client who had cardiac surgery notes that the client's cardiac
output immediately after surgery was 3.2 L/min. Evaluation of the cardiac output results leads the nurse
to make which conclusion? - CORRECT ANS The cardiac output is below the normal range.
The nurse is caring for an older client. Which finding should the nurse expect to note in this client while
evaluating renal function? - CORRECT ANS The glomerular filtration rate (GFR) diminishes.
As part of the normal aging process, the GFR decreases, along with each of the other functional abilities
of the kidney. Tubular reabsorption and urine-concentrating ability also decrease. The kidneys have
decreased ability to metabolize medications.
A client with a history of opiate abuse asks the nurse, "Why do I crave this stuff so much?" The nurse
responds, knowing that the client's craving is a result of which factor? - CORRECT ANS Lack of naturally
occurring endorphins.
Craving opiates is a result of the diminished production of endorphins that occurs with long-term abuse
of the drug.
A burn-injured client is receiving treatments of topical mafenide acetate to the site of injury. The nurse
should monitor the client for which systemic effect that can occur from the use of this medication? -
CORRECT ANS Acidosis.
Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby
causing acidosis. Clients receiving this treatment should be monitored for acidosis, and if the acidosis
becomes severe, the medication should be discontinued for 1 to 2 days.
The nurse discovers a fire in the trash basket in a client's bathroom. The nurse assists the client out of
the hospital room to a safe place, activates the fire alarm, and takes which action next? - CORRECT ANS
Closes the doors to the other clients' rooms.
In the event of a fire, the first priority is to rescue the client and protect the client from injury. The next
priority is to activate the fire alarm and report the exact location of the fire to emergency personnel to
aid in the rescue process. Next, the nurse would contain the fire by closing doors and placing towels
,under the doorways to prevent the spread of smoke. The nurse then would obtain the fire extinguisher,
pull the pin, and extinguish the fire.
Which specific nursing interventions are implemented in the care of a child with leukemia who is at risk
for infection? Select all that apply. - CORRECT ANS Reduce exposure to environmental organisms.
Use strict aseptic technique for all procedures.
Ensure that anyone entering the child's room wears a mask.
Measures to prevent infection include the use of a private room, strict aseptic technique, restriction of
visitors and health care personnel with active infection, strict hand washing, ensuring that anyone
entering the child's room wears a mask, and reducing exposure to environmental organisms by
eliminating raw fruits and vegetables from the diet and fresh flowers from the child's room and by not
leaving standing water in the child's room. Applying firm pressure to a needle-stick area for at least 10
minutes is a measure to prevent bleeding.
The nurse is providing instructions to a client regarding food items that are high in vitamin D. The client
demonstrates understanding of the instructions by stating the need to include which food item in the
diet? - CORRECT ANS Milk.
Milk provides the highest amount of vitamin D. Broccoli and oranges are high in vitamin C, and meat is
high in vitamin B complex.
The nurse is reviewing the laboratory results of a client admitted to the hospital with a diagnosis of
venous thrombosis. The nurse expects the platelet aggregation to be reported as which level in this
client? - CORRECT ANS Increased.
The adherence of platelets to one another is defined as platelet aggregation. Platelets usually aggregate
in less than 5 minutes. This test determines abnormalities in the rate and percentage of platelet
aggregation. Increased platelet aggregation may occur after surgery or with acute illness, venous
thrombosis, and pulmonary embolism.
A client with benign prostatic hyperplasia undergoes a transurethral resection of the prostate.
Postoperatively the client is receiving continuous bladder irrigations. The nurse assesses the client for
manifestations of transurethral resection syndrome. Which assessment data would indicate the onset of
this syndrome? - CORRECT ANS Bradycardia and confusion.
, Transurethral resection syndrome is caused by increased absorption of nonelectrolyte irrigating fluid
used during surgery. The client may show signs of cerebral edema and increased intracranial pressure,
such as increased blood pressure, bradycardia, confusion, disorientation, muscle twitching, visual
disturbances, and nausea and vomiting.
The nurse is performing an assessment on an older adult client. Which assessment data would indicate a
potential complication associated with the skin? - CORRECT ANS Crusting.
The normal physiological changes that occur in the skin of older adults include thinning of the skin, loss
of elasticity, deepening of expression lines, and wrinkling. Crusting noted on the skin would indicate a
potential complication.
The nurse is caring for a client who has had spinal fusion, with insertion of hardware. The nurse would
be most concerned with which assessment finding? - CORRECT ANS Temperature of 101.6° F (38.7° C)
orally.
Watches for signs and symptoms of infection, and inspects the surgical site for evidence of cerebrospinal
fluid leakage (drainage is clear and tests positive for glucose). A mild temperature is expected after
insertion of hardware, but a temperature of 101.6° F (38.7° C) should be reported.
Glimepiride is prescribed for a client with diabetes mellitus. The nurse instructs the client that which
food items are most acceptable to consume while taking this medication? Select all that apply. -
CORRECT ANS Red meats.
Whole-grain cereals.
Carbonated beverages.
When alcohol is combined with glimepiride, a disulfiram-like reaction may occur. This syndrome includes
flushing, palpitations, and nausea. Alcohol can also potentiate the hypoglycemic effects of the
medication. Clients need to be instructed to avoid alcohol consumption while taking this medication.
Low-calorie desserts should also be avoided.
The nurse working in a long-term care facility notes that several clients are taking pilocarpine
hydrochloride eye drops. The nurse ensures that which medication is available on the nursing unit for
use if a client should develop systemic toxicity from pilocarpine hydrochloride? - CORRECT ANS
Atropine sulfate.
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