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SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX ONE (1004 QUESTIONS AND ANSWERS )

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1) The nurse is providing discharge instructions to a Chinese American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nur... se. The nurse should implement which best action?  Answers-Continue with the instructions, verifying client understanding. 1) 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. 2) 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 3) 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." 4) 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 5) When communicating with a client who speaks a different language, which best practice should the nurse implement?  Arrange for an interpreter to translate. 6) 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." 7) 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 8) 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. 9) 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 10) 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). 11) 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?  "Magnetic therapy and massage therapy are a focus of CAM." 12) 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. 13) 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. 14) 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. 15) 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?  Clarify with the team leader to make a safe ICU client assignment. 16) 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. 17) 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." 19) 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.20) 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. 21) 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 22) 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 23) 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." 24) 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. 25) 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. 26) The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?  A client with asthma who requested a breathing treatment during the previous shift 27) 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?  A client with chest pain who states that he just ate pizza that was made with a very spicy sauce 28) 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 nursingmodel is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice?  An RN leads 2 licensed practical nurses (LPNs) and 3 UAPs in providing care to a group of 12 clients. 29) 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?  A client with a white blood cell count of 14,000 mm3 (14.0 × 109/L) and a temperature of 101°F (38.4°C) 30) 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?  Cover the client, raise the side rails, tell the client that you will return shortly, and administer the pain medication to the other client. 31) 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?  Confront the UAP to encourage verbalization of feelings regarding the change.32) The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an unlicensed assistive personnel (UAP)?  A client who requires urine specimen collections 33) 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.  Move beds away from windows.  Close window shades and curtains.  Place blankets over clients who are confined to bed. 34) 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?  A client requiring abdominal wound irrigations and dressing changes every 3 hours 35) 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.  The acuity level of the clients  Client needs and workers' needs and abilities 36) 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 additionalmanifestations would the nurse expect to note in this client if excess fluid volume is present?  An increase in blood pressure and increased respirations 37) 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?  Requires nasogastric suction 38) 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.  U waves  Inverted T waves  Depressed ST segment 39) 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.  Obtain an intravenous (IV) infusion pump.  Monitor urine output during administration.  Monitor the IV site for signs of infiltration or phlebitis.  Ensure that the medication is diluted in the appropriate volume of fluid. Ensure that the bag is labeled so that it reads the volume of potassium in the solution. 40) 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.  Raisins  Potatoes  Cantaloupe  Strawberries 41) 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.  Peas  Nuts  Cauliflower 42) The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client?  Twitching 43) 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.  Prolonged QT interval  Prolonged ST segment44) 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.  Tall peaked T waves  Widened QRS complexes 45) Which client is at risk for the development of a sodium level at 130 mEq/L (130 mmol/L)?  The client who is taking diuretics 46) 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?  Hyperactive bowel sounds 47) 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?  Malnutrition 48) 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?  Integumentary output 49) 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? A client with an ileostomy 50) 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?  Weight loss and poor skin turgor 51) On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess?  The client with kidney disease and a 12-year history of diabetes mellitus 52) Which client is at risk for the development of a potassium level of 5.5mEq/L (5.5 mmol/L)?  The client who has sustained a traumatic burn 53) 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 54) 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 55) 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 HCO3–56) 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 = 72 mm Hg (72 mm Hg), Paco2 = 32 mmHg (32 mm Hg), and HCO3– = 28 mEq/L (28 mmol/L). Which conclusion about the client should the nurse make?  The client is probably hyperventilating. 57) 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 deep 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 59) 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 60) 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)61) 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) 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 63) 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 64) 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." 65) 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) 66) The nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel (UAP). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching?  Taking an oral temperature for a client with a cough and nasal congestion 67) A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. Theclient's activated partial thromboplastin time (aPTT) is 65 seconds. The nurse anticipates that which action is needed? 68) A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide?  Leaving the rate of the heparin infusion as is 69) A client with a history of cardiac disease is due for a morning dose of furosemide. Which serum potassium level, if noted in the client's laboratory report, should be reported before administering the dose of furosemide?  3.2 mEq/L (3.2 mmol/L) 70) Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply.  Platelets 35,000 mm3 (35 × 109/L)  Sodium 150 mEq/L (150 mmol/L)  Segmented neutrophils 40% (0.40)  White blood cells, 3000 mm3 (3.0 × 109/L) 71) The nurse is caring for a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history, and determines it is necessary to contact the health care provider (HCP) if the client is also taking which medications? Select all that apply.  Warfarin  Glimepiride  Amlodipine 72) A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 9%. On the basis of this test result, the nurse plans to teach the client about the need for which measure?  Preventing and recognizing hyperglycemia 73) The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would consider implementing neutropenic precautions if the client's white blood cell count was which value?  2000 mm3 (2.0 × 109/L) 74) A client brought to the emergency department states that he has accidentally been taking 2 times his prescribed dose of warfarin for the past week. After noting that theclient has no evidence of obvious bleeding, the nurse plans to take which action?  Draw a sample for prothrombin time (PT) and international normalized ratio (INR). 75) The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2°F (36.2°C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should the nurse take next?  Attempt to arouse the client. 76) An adult female client has a hemoglobin level of 10.8 g/dL (108 mmol/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history?  Iron deficiency anemia 77) A client with a history of gastrointestinal bleeding has a platelet count of 300,000 mm3 (300 × 109/L). The nurse should take which action after seeing the laboratory results?  Place the normal report in the client's medical record. 78) The nurse is teaching a client who has iron deficiency anemia about foods she should include in the diet. The nurse determines that the client understands the dietary modifications if which items are selected from the menu?  Oranges and dark green leafy vegetables 79) The nurse is planning to teach a client with malabsorption syndrome about the necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food items on the list? Select all that apply.  Margarine  Cream cheese  Luncheon meats80) The nurse instructs a client with chronic kidney disease who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu?  Cream of wheat, blueberries, coffee 81) The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet?  Vitamin B12 82) A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client?  Summer squash 83) A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply.  Broth  Coffee  Gelatin 84) The nurse is instructing a client with hypertension on the importance of choosing foods low in sodium. The nurse should teach the client to limit intake of which food?  Smoked sausage 85) A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been "bored" with the clear liquid diet. The nurse should offer which full liquid item to the client?  Custard 86) A client is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing?  Oranges 87) The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client hasthe best understanding of the dietary measures to follow if the client states an intention to increase the intake of which food?  Legumes 88) A client is being weaned from parenteral nutrition (PN) and is expected to begin taking solid food today. The ongoing solution rate has been 100 mL/hour. The nurse anticipates that which prescription regarding the PN solution will accompany the diet prescription?  Decrease PN rate to 50 mL/hour. 89) The nurse is preparing to change the parenteral nutrition (PN) solution bag and tubing. The client's central venous line is located in the right subclavian vein. The nurse asks the client to take which essential action during the tubing change?  Take a deep breath, hold it, and bear down. 90) A client with parenteral nutrition (PN) infusing has disconnected the tubing from the central line catheter. The nurse assesses the client and suspects an air embolism. The nurse should immediately place the client in which position?  On the left side, with the head lower than the feet 91) Which nursing action is essential prior to initiating a new prescription for 500 mL of fat emulsion (lipids) to infuse at 50 mL/hour?  Determine whether the client has an allergy to eggs. 92) The nurse monitors the client receiving parenteral nutrition (PN) for complications of the therapy and should assess the client for which manifestations of hyperglycemia?  Weakness, thirst, and increased urine output 93) The nurse is changing the central line dressing of a client receiving parenteral nutrition (PN) and notes that the catheter insertion site appears reddened. The nurse should next assess which item?  Client's temperature 94) The nurse is preparing to hang fat emulsion (lipids) and notes that fat globules are visible at the top of the solution. The nurse should take which action?  Obtain a different bottle of solution.95) A client receiving parenteral nutrition (PN) suddenly develops a fever. The nurse notifies the health care provider (HCP), and the HCP initially prescribes that the solution and tubing be changed. What should the nurse do with the discontinued materials?  Prepare to send them to the laboratory for culture. 96) A client has been discharged to home on parenteral nutrition (PN). With each visit, the home care nurse should assess which parameter most closely in monitoring this therapy?  Temperature and weight 97) The nurse, caring for a group of adult clients on an acute care medical-surgical nursing unit, determines that which clients would be the most likely candidates for parenteral nutrition (PN)? Select all that apply.  A client with extensive burns  A client with cancer who is septic  A client with severe exacerbation of Crohn's disease  A client with persistent nausea and vomiting from chemotherapy 98) The nurse is preparing to hang the first bag of parenteral nutrition (PN) solution via the central line of an assigned client. The nurse should obtain which most essential piece of equipment before hanging the solution?  Electronic infusion pump 99) The nurse is making initial rounds at the beginning of the shift and notes that the parenteral nutrition (PN) bag of an assigned client is empty. Which solution should the nurse hang until another PN solution is mixed and delivered to the nursing unit?  10% dextrose in water 100) The nurse is monitoring the status of a client's fat emulsion (lipid) infusion and notes that the infusion is 1 hour behind. Which action should the nurse take?  Ensure that the fat emulsion infusion rate is infusing at the prescribed rate 101) A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The nurse should next assess the client for the presence of which condition? Crackles on auscultation of the lungs 102) The nurse is caring for a restless client who is beginning nutritional therapy with parenteral nutrition (PN). The nurse should plan to ensure that which action is taken to prevent the client from sustaining injury?  Secure all connections in the PN system. 103) A client receiving parenteral nutrition (PN) complains of a headache. The nurse notes that the client has an increased blood pressure, bounding pulse, jugular vein distention, and crackles bilaterally. The nurse determines that the client is experiencing which complication of PN therapy?  Hypervolemia 104) A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse making rounds at 1545 finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills, and apprehensive, with an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first?  Slow the IV infusion. 105) The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride. The nurse also needs to hang an IV infusion of piperacillin/tazobactam. The client has one IV site. The nurse should plan to take which action first?  Check compatibility of the medication and IV fluids. 106) The nurse is completing a time tape for a 1000-mL intravenous (IV) bag that is scheduled to infuse over 8 hours. The nurse has just placed the 1100 marking at the 500-mL level. The nurse would place the mark for 1200 at which numerical level (mL) on the time tape? Fill in the blank.  375ml 107) The nurse is making initial rounds on the nursing unit to assess the condition of assigned clients. Which assessment findings are consistent with infiltration? Select all that apply.  Pallor and coolness  Numbness and pain  Edema and blanched skin108) The nurse is inserting an intravenous (IV) line into a client's vein. After the initial stick, the nurse would continue to advance the catheter in which situation?  Blood return shows in the backflash chamber of the catheter. 109) The nurse is assessing a client's peripheral intravenous (IV) site after completion of a vancomycin infusion and notes that the area is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. At this time, which action by the nurse is best?  Remove the IV site and restart at another site. 110) The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action?  Obtain new IV tubing 111) A health care provider has written a prescription to discontinue an intravenous (IV) line. The nurse should obtain which item from the unit supply area for applying pressure to the site after removing the IV catheter?  Sterile 2 × 2 gauze 112) A client rings the call light and complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which actions in the care of this client? Select all that apply.  Remove the IV catheter at that site.  Apply warm moist packs to the site.  Notify the health care provider (HCP).  Document the occurrence, actions taken, and the client's response. 113) A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which intravenous (IV) solution will most likely be prescribed for this client? 5% dextrose in lactated Ringer's solution 114) he nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instructions if the client made which statement?  "I need to restrict my activity while this catheter is in place." 115) A client has just undergone insertion of a central venous catheter at the bedside under ultrasound. The nurse would be sure to check which results before initiating the flow rate of the client's intravenous (IV) solution at 100 mL/hour?  Chest radiology results 116) Intravenous (IV) fluids have been infusing at 100 mL/hour via a central line catheter in the right internal jugular for approximately 24 hours to increase urine output and maintain the client's blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and coughing. For which additional signs of a complication should the nurse assess based on the previously known data?  Crackles in the lungs 117) Packed red blood cells have been prescribed for a female client with a hemoglobin level of 7.6 g/dL (76 mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the client's temperature before hanging the blood transfusion and records 100.6°F (38.1°C) orally. Which action should the nurse take?  Delay hanging the blood and notify the health care provider (HCP). 118) he nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which initial question?  "Have you ever had a transfusion before?" 119) A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client's temperature is 100.8°F (38.2°C) orally from a baseline of 99.2°F (37.3°C) orally. The nurse determines that the clientmay be experiencing which complication of a blood transfusion?  Septicemia 120) The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next?  Run normal saline at a keepvein-open rate. 121) The nurse has just received a unit of packed red blood cells from the blood bank for transfusion to an assigned client. The nurse is careful to select tubing especially made for blood products, knowing that this tubing is manufactured with which item? Click on the image to indicate your answer.  Correct Answer Indication: 122) A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which finding?  Decreased oozing of blood from puncture sites and gums 123) A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which finding?  Decreased oozing of blood from puncture sites and gums 124) The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which priority item?  Vital signs 125) The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. What action should the nurse take next?  Check to be sure that consent for the transfusion has been signed. 126) Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, boundingpulses, crackles, and wheezes. Which action should the nurse implement first?  Place the client in high Fowler's position. 127) The nurse, listening to the morning report, learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which daily serum laboratory studies to assess the effectiveness of the transfusion?  White blood cell count 128) A client is brought to the emergency department having experienced blood loss related to an arterial laceration. Which blood component should the nurse expect the health care provider to prescribe?  Fresh-frozen plasma 129) The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. The nurse takes which actions in order to prevent a complication of the blood transfusion as it relates to deterioration of blood cells? Select all that apply.  Checks the expiration date  Hangs the blood within the specified time frame per agency policy 130) A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to take which actions to reduce the risk of possible transfusion complications? Select all that apply.  Ask a family member to donate blood ahead of time.  Give an autologous blood donation before the surgery. 131) A client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood. The nurse asks another health team member to obtain whichdevice for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias?  Blood-warming device 132) A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which intravenous (IV) solution from the IV storage area to hang with the blood product at the client's bedside?  0.9% sodium chloride 133) The nurse is caring for a client who is receiving a blood transfusion and is complaining of a cough. The nurse checks the client's vital signs, which include temperature of 97.2°F (36.2°C), pulse of 108 beats per minute, blood pressure of 152/76 mm Hg, respiratory rate of 24 breaths per minute, and an oxygen saturation level of 95% on room air. The client denies pain at this time. Based on this information, what initial action should the nurse take?  Compare current data to baseline data. 134) A Spanish-speaking client arrives at the triage desk in the emergency department and states to the nurse, "No speak English, need interpreter." Which is the best action for the nurse to take?  Page an interpreter from the hospital's interpreter services. 135) The nurse is performing a neurological assessment on a client and elicits a positive Romberg's sign. The nurse makes this determination based on which observation?  A significant sway when the client stands erect with feet together, arms at the side, and the eyes closed 136) The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding?  Rhythmic respirations with periods of apnea137) A client diagnosed with conductive hearing loss asks the nurse to explain the cause of the hearing problem. The nurse plans to explain to the client that this condition is caused by which problem?  A physical obstruction to the transmission of sound waves 138) While performing a cardiac assessment on a client with an incompetent heart valve, the nurse auscultates a murmur. The nurse documents the finding and describes the sound as which?  A blowing or swooshing noise 139) The nurse is testing the extraocular movements in a client to assess for muscle weakness in the eyes. The nurse should implement which assessment technique to assess for muscle weakness in the eye?  Test the 6 cardinal positions of gaze. 140) The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam?  After a shower or bath 141) The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe?  The client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. 142) A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client?  Wheezes 143) The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply. Auscultating lung sounds  Obtaining the client's temperature  Obtaining information about the client's respirations 144) The nurse is preparing to initiate an intravenous (IV) line containing a high dose of potassium chloride and plans to use an IV infusion pump. The nurse brings the pump to the bedside, prepares to plug the pump cord into the wall, and notes that no receptacle is available in the wall socket. The nurse should take which action?  Contact the electrical maintenance department for assistance. 145) The nurse obtains a prescription from a health care provider to restrain a client and instructs an unlicensed assistive personnel (UAP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required by the UAP?  Safely securing the safety device straps to the side rails 146) The community health nurse is providing a teaching session about anthrax to members of the community and asks the participants about the methods of transmission. Which answers by the participants would indicate that teaching was effective? Select all that apply.  Inhalation of bacterial spores  Through a cut or abrasion in the skin  Ingestion of contaminated undercooked meat 147) The nurse is giving a report to an unlicensed assistive personnel (UAP) who will be caring for a client who has hand restraints (safety devices). The nurse instructs the UAP tocheck the skin integrity of the restrained hands how frequently?  Every 30 minutes 148) The nurse is reviewing a plan of care for a client with an internal radiation implant. Which intervention, if noted in the plan, indicates the need for revision of the plan?  Placing the client in a semiprivate room at the end of the hallway 149) Contact precautions are initiated for a client with a health care–associated (nosocomial) infection caused by methicillin-resistant Staphylococcus aureus. The nurse prepares to provide colostomy care and should obtain which protective items to perform this procedure?  Gloves, gown, goggles, and a mask or face shield 150) The nurse enters a client's room and finds that the wastebasket is on fire. The nurse immediately assists the client out of the room. What is the next nursing action?  Activate the fire alarm. 151) A mother calls a neighbor who is a nurse and tells the nurse that her 3-year-old child has just ingested liquid furniture polish. The nurse would direct the mother to take which immediate action?  Call the Poison Control Center. 152) The emergency department (ED) nurse receives a telephone call and is informed that a tornado has hit a local residential area and that numerous casualties have occurred. The victims will be brought to the ED. The nurse should take which initial action?  Activate the emergency response plan. 153) The nurse is caring for a client with meningitis and implements which transmission-based precautions for this client? Private room or cohort client 154) The nurse working in the emergency department (ED) is assessing a client who recently returned from Liberia and presented complaining of a fever at home, fatigue, muscle pain, and abdominal pain. Which action should the nurse take next?  Isolate the client in a private room. 155) A health care provider's prescription reads 1000 mL of normal saline (NS) to infuse over 12 hours. The drop factor is 15 drops (gtt)/1 mL. The nurse prepares to set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.  21 drops per minute 156) A health care provider's prescription reads to administer an intravenous (IV) dose of 400,000 units of penicillin G benzathine. The label on the 10-mL ampule sent from the pharmacy reads penicillin G benzathine, 300,000 units/mL. The nurse prepares how much medication to administer the correct dose? Fill in the blank. Record your answer using 1 decimal place.  1.3 mL 157) A health care provider's prescription reads potassium chloride 30 mEq to be added to 1000 mL normal saline (NS) and to be administered over a 10-hour period. The label on the medication bottle reads 40 mEq/20 mL. The nurse prepares how many milliliters of potassium chloride to administer the correct dose of medication? Fill in the blank.  15 mL 158) A health care provider's prescription reads clindamycin phosphate 0.3 g in 50 mL normal saline (NS) to be administered intravenously over 30 minutes. The medication label reads clindamycin phosphate 900 mg in 6 mL. The nurse prepares how many milliliters of the medication to administer the correct dose? Fill in the blank.  2 mL 159) A health care provider's prescription reads phenytoin 0.2 g orally twice daily. The medication label states thateach capsule is 100 mg. The nurse prepares how many capsule(s) to administer 1 dose? Fill in the blank.  2 capsule(s) 160) A health care provider prescribes 1000 mL of normal saline 0.9% to infuse over 8 hours. The drop factor is 15 drops (gtt)/1 mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.  31 drops per minute 161) A health care provider prescribes heparin sodium, 1300 units/hour by continuous intravenous (IV) infusion. The pharmacy prepares the medication and delivers an IV bag labeled heparin sodium 20,000 units/250 mL D5W. An infusion pump must be used to administer the medication. The nurse sets the infusion pump at how many milliliters per hour to deliver 1300 units/hour? Fill in the blank. Record your answer to the nearest whole number.  16 mL per hour 162) A health care provider prescribes 3000 mL of D5W to be administered over a 24-hour period. The nurse determines that how many milliliters per hour will be administered to the client? Fill in the blank.  125 mL per hour 163) Gentamicin sulfate, 80 mg in 100 mL normal saline (NS), is to be administered over 30 minutes. The drop factor is 10 drops (gtt)/1 mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.  33 drops per minute 164) A health care provider's prescription reads levothyroxine, 150 mcg orally daily. The medication label reads levothyroxine, 0.1 mg/tablet. The nurse administers how many tablet(s) to the client? Fill in the blank.  1.5 tablet(s) 165) Cefuroxime sodium, 1 g in 50 mL normal saline (NS), is to be administered over 30 minutes. The drop factor is 15 [Show More]

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