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SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FOUR: (1141 Questions and Answers)

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HERE LISTS ONLY THE FIRST 210 QUESTIONS SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FOUR 1) The nurse would anticipate that the health care provider (HCP) would add which medication to the regimen of ... the client receiving isoniazid? 2) A postpartum nurse is caring for a client with an epidural catheter in place for opioid analgesic administration following cesarean birth. The client develops respiratory depression and requires naloxone administration. Which finding should the nurse anticipate as a result of the naloxone administration? 3) The nurse should monitor the client receiving the first dose of albuterol for which side or adverse effect of this medication? 4) The client has a prescription to receive pirbuterol 2 puffs and beclomethasone dipropionate 2 puffs by metered-dose inhaler. The nurse plans to give these medications in which way to ensure 5) A client with chronic obstructive pulmonary disease (COPD) is being changed from an oral glucocorticoid to triamcinolone by inhalation. The client asks why this change is necessary. Which statement by the nurse to the client is accurate? 6) A client taking theophylline has a serum theophylline level of 15 mcg/mL (60 mcmol/L). How does the nurse interpret this laboratory value? 7) A client is taking cetirizine. The nurse should inform the client of which side effect of this medication? 8) A client is scheduled to receive acetylcysteine 20% solution diluted in 0.9% normal saline by nebulizer. Which outcome would the nurse expect as a result of the administration of this medication? 9) The health care provider prescribes cromolyn for the client with asthma. The nurse identifies that the client correctly understands the purpose of this medication when the client states that the medication will produce which effect?  10) The nurse is teaching a client about the effects of diphenhydramine, an ingredient in the cough suppressant prescribed for the client. The nurse should plan to tell the client to take which measure while taking this medication? 11) The health care provider (HCP) has prescribed codeine sulfate for a client with a nonproductive cough to suppress the cough reflex. The nurse should teach the client to monitor for which side effect of the medication? 12) A client has begun therapy with a xanthine bronchodilator. The nurse determines that the client understands dietary alterations if the client states to limit which items while taking this medication? Select all that apply. 13) Which supplies should the nurse obtain for the administration of ribavirin to a hospitalized child with respiratory syncytial virus (RSV)? 14) The nurse is documenting information in a client's chart when the electrocardiogram telemetry alarm sounds, and the nurse notes that the client is in ventricular tachycardia (VT). The nurse rushes to the client's bedside and should perform which assessment first? 15) A client is brought into the emergency department in ventricular fibrillation (VF). The nurse prepares to defibrillate by placing defibrillation pads on which part of the chest? 16) An adult client has been unsuccessfully defibrillated for ventricular fibrillation, and cardiopulmonary resuscitation (CPR) is resumed. The nurse confirms that CPR is being administered effectively by noting which action 17) The nurse is assigned the care of a client who experienced a myocardial infarction and is being monitored by cardiac telemetry. The nurse notes the sudden onset of this cardiac rhythm on the monitor. The nurse should immediately take which action? Refer to Figure. View Figure 18) To perform defibrillation, the defibrillator pads should be placed in which areas of the client's chest? 19) The nurse is caring for a client who is pulseless and experiencing this dysrhythmia. Which interventions should the nurse anticipate implementing in collaboration with the health care provider (HCP)? Select all that apply. Refer to Figure. View Figure 20) The nurse is performing cardiopulmonary resuscitation (CPR) on a client who has had a cardiac arrest. An automatic external defibrillator (AED) is available to treat the client. Which activity will allow the nurse to assess the client's cardiac rhythm? 21) The nurse is teaching adult cardiopulmonary resuscitation (CPR) guidelines to a group of laypeople. The nurse observes the group correctly demonstrate 2-rescuer CPR when which ratio of compressions to ventilations is performed on the mannequin? 22) The nurse is teaching cardiopulmonary resuscitation (CPR) to a group of community members. The nurse tells the group that when chest compressions are performed on infants, the sternum should be depressed how far?  ) 23) The nursing instructor teaches a group of students about cardiopulmonary resuscitation. The instructor asks a student to identify the most appropriate location at which to assess the pulse of an infant younger than 1 year of age. Which response would indicate that the student understands the appropriate assessment procedure? 24) The nurse is conducting a basic life support (BLS) recertification class and is discussing chest compressions in a pregnant woman. The nurse should tell the class that which action should be taken in an advanced pregnancy client whose fundal height is at or above the umbilicus? 25) The nurse is initiating 1-rescuer cardiopulmonary resuscitation on an adult client. The nurse should place the hands in which position to begin chest compressions? 26) The nurse walking in a downtown business area witnesses a worker fall from a ladder. The nurse rushes to the victim, who is unresponsive. A layperson is attempting to perform resuscitative measures. The nurse should intervene if which action by the layperson is noted? 27) The nurse notes that a 14-year-old child is choking but is awake and alert at this time. The nurse rushes to perform the abdominal thrust maneuver. The child becomes unconscious. What procedure should the nurse perform next? 28) The nurse assigned to the pediatric unit finds an infant unresponsive and without respirations or a pulse. What is the nurse's next action after calling for help? 29) The nurse is undergoing annual recertification in basic life support (BLS). The BLS instructor asks the nurse to identify the pulse point to use when determining pulselessness on an infant. Which response by the nurse identifies the most appropriate pulse point? 30) External public access defibrillator (PAD) interprets that the rhythm of a pulseless victim is ventricular fibrillation and advises defibrillation. Which action should the rescuer take next? 31) Cardiopulmonary resuscitation (CPR) is immediately initiated on a client who is unconscious and has no pulse. A monitor is attached and it is determined that the rhythm is shockable, and defibrillation with 1 shock is delivered. Which action should the nurse plan to take next? 32) The nurse has completed 5 cycles of compressions after beginning cardiopulmonary resuscitation (CPR) on a hospitalized adult client who experienced unmonitored cardiac arrest. What should the nurse plan to do next? 33) The nurse is teaching chest compressions for cardiopulmonary resuscitation (CPR) to a group of lay clients. Which behavior by one of the participants indicates a need for further teaching? 34) In order of priority, how should the nurse perform abdominal thrusts on an unconscious adult? Arrange the actions in the order that they should be performed. All options must be used. 35) One unit of packed red blood cells has been prescribed for a client with severe anemia. The client has received multiple transfusions in the past, and it is documented that the client has experienced urticaria-type reactions from the transfusions. The nurse anticipates that which medication will be prescribed before administration of the red blood cells to prevent this type of reaction? 36) The nurse has a prescription to administer whole blood to a client who does not currently have an intravenous (IV) line inserted. When obtaining supplies to start the blood infusion, the nurse should select an angiocatheter of at least which size? 37) A client has experienced high blood pressure and crackles in the lungs during previous blood transfusions. The client asks the nurse whether it is safe to receive another transfusion. The nurse explains that which medication most likely will be prescribed before the transfusion is begun? 38) The nurse is told by a health care provider that a client in hypovolemic shock will require plasma expansion. The nurse should prepare which supplies for transfusion? 39) The nurse has discontinued a unit of blood that was infusing into a client because the client experienced a transfusion reaction. After documenting the incident appropriately, the nurse sends the blood bag and tubing to which department? 40) The nurse has just obtained a unit of blood from the blood bank to transfuse into a client as prescribed. Before preparing the blood for transfusion, the nurse looks for which member of the health care team to assist in checking the unit of blood? 41) The nurse is picking up a unit of packed red blood cells at the hospital blood bank. After putting the pen down, the nurse glances at the clock, which reads 1300. The nurse calculates that the transfusion must be started by which time? 42) The nurse enters a client's room to assess the client, who began receiving a blood transfusion 45 minutes earlier, and notes that the client is flushed and dyspneic. On assessment, the nurse auscultates the presence of crackles in the lung bases. The nurse determines that this client most likely is experiencing which complication of blood transfusion therapy? 43) The nurse is monitoring a client who is receiving a blood transfusion. After 30 minutes of the infusion, the client begins to have chills and back pain. His temperature is 100.1°F (37.8°C). What action should the nurse take first?  Discontinue the infusion and start an infusion of normal saline using new tubing. 44) The nurse enters the room of a client who began receiving a blood transfusion 45 minutes earlier to check on the client. The client is complaining of "itching all over" and has a generalized rash. The client's temperature has not changed from baseline and the lungs are clear to auscultation. Which complication of blood transfusion therapy should the nurse determine that this client is most likely experiencing?  Allergic transfusion reaction 45) A unit of platelets was just received from the blood bank for transfusion to an assigned client. The nurse should select tubing with which feature for the transfusion?  An in-line filter 46) The nurse overhears a health care provider (HCP) stating that a client diagnosed with disseminated intravascular coagulation (DIC) requires a transfusion. Which blood product should the nurse anticipate that the HCP will write a prescription for?  Cryoprecipitate 47) The nurse is assisting in monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs). Before leaving the room, the nurse tells the client to immediately report which symptoms of a transfusion reaction? Select all that apply.  Chills  Chest pain  Lower back pain  Difficulty breathing 48) A child is receiving succimer for the treatment of lead poisoning. The nurse should monitor which most important laboratory result?  Blood urea nitrogen level 49) A client with a probable minor head injury resulting from a motor vehicle crash is admitted to the hospital for observation. The nurse leaves the cervical collar applied to the client in place until when?  The results of spinal radiography are known 50) A client experienced an open pneumothorax (sucking wound), which has been covered with an occlusive dressing. The client begins to experience severe dyspnea, and the blood pressure begins to fall. The nurse should first perform which action?  Remove the dressing. 51) The nurse is performing an assessment on a client admitted to the nursing unit who has sustained an extensive burn injury involving 45% of total body surface area. When planning for fluid resuscitation, the nurse should consider that fluid shifting to the interstitial spaces is greatest during which time period?  Between 18 and 24 hours after the injury 52) The nurse in the recovery room is caring for a client who underwent neurosurgery. Sequential compression devices (SCDs) have been applied to prevent venous stasis. While awaiting client transfer to the intensive care unit, the recovery room nurse should perform which critical assessment?  Monitor vascular status of the lower extremities. 53) A pulmonary artery catheter is inserted into a client during cardiac surgery. The nurse is monitoring the right atrial pressure (RAP). Which finding requires immediate nursing intervention?  12 mm Hg 54) The nursing educator has just completed a lecture to a group of nurses regarding care of the client with a burn injury. A major aspect of the lecture was care of the client at the scene of a fire. Which statement, if made by a nurse, indicates a need for further instruction?  "The client should be maintained in a standing position." 55) The community health nurse is providing a teaching session to firefighters in a small community regarding care of a burn victim at the scene of injury. The nurse instructs the firefighters that in the event of a tar burn, which is the immediate action?  Cooling the injury with water 56) The industrial nurse is providing instructions to a group of employees regarding care to a client in the event of a chemical burn injury. The nurse instructs the employees that which is the first consideration in immediate care?  Removing all clothing, including gloves, shoes, and any undergarments 57) A client who sustained an inhalation injury arrives in the emergency department. On initial assessment, the nurse notes that the client is very confused and combative. The nurse determines that the client is most likely experiencing which condition?  Hypoxia 58) A client is brought to the emergency department immediately after a smoke inhalation injury. The nurse initially prepares the client for which treatment?  100% humidified oxygen by face mask 59) The nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area from a fire. Which assessment finding would indicate that the client sustained a respiratory injury as a result of the burn?  Use of accessory muscles for breathing 60) The nurse is performing an assessment on a client who sustained circumferential burns of both legs. Which assessment would be the initial priority in caring for this client?  Assessing peripheral pulses 61) The nurse is developing a plan of care for a client who sustained an inhalation burn injury. Which nursing intervention should the nurse include in the plan of care for this client?  Elevate the head of the bed. 62) The nurse has developed a nursing care plan for a client with a burn injury to implement during the emergent phase. Which priority intervention should the nurse include in the plan of care?  Monitor mental status every hour. 63) The nurse is developing a nursing care plan for a client with a circumferential burn injury of the right arm. What is the nurse's priority action?  Monitor the radial pulse every hour. 64) Vasopressin is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse should prepare to administer this medication by which route?  By intravenous infusion 65) Vasopressin therapy is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse is preparing to administer the medication to the client. Which essential item is needed during the administration of this medication?  A cardiac monitor 66) The nurse is monitoring a client who required a Sengstaken-Blakemore tube because other measures for treating bleeding esophageal varices were unsuccessful. The client complains of severe pain of abrupt onset. Which nursing action is most appropriate?  Cut the tube. 67) A postpartum client who received an epidural analgesic after giving birth by cesarean section is lethargic and has a respiratory rate of 8 breaths per minute. The nurse should obtain which medication from the emergency cart after notifying the health care provider?  Naloxone 68) The nurse is reviewing the medical record of a client transferred to the medical unit from the critical care unit. The nurse notes that the client received intra-aortic balloon pump (IABP) therapy while in the critical care unit. The nurse suspects that the client received this therapy for which condition?  Cardiogenic shock 69) The nurse is providing care for a client who sustained burns over 30% of the body from a fire. On assessment, the nurse notes that the client is edematous in both burned and unburned body areas. The client's wife asks why her husband "looks so swollen." What is the nurse's best response?  "Leaking blood vessels have led to decreased protein amounts in the blood." 70) The emergency department nurse is monitoring a client who received treatment for a severe asthma attack. The nurse determines that the client's respiratory status has worsened if which is noted on assessment?  Diminished breath sounds 71) The nurse is performing an assessment on a client who was admitted with a diagnosis of carbon monoxide poisoning. Which assessment performed by the nurse would primarily elicit data related to a deterioration of the client's condition?  Level of consciousness 72) The nurse is reviewing the laboratory test results for a client admitted to the burn unit 3 hours after an explosion that occurred at a worksite. The client has a severe burn injury that covers 35% of the total body surface area (TBSA). The nurse is most likely to note which finding on the laboratory report?  Hematocrit 60% (0.60) 73) The nurse is caring for a client who sustained a thermal burn caused by the inhalation of steam 24 hours ago. The nurse determines that the priority nursing action is to assess which item?  Lung sounds 74) A client with depression receiving phenelzine sulfate suddenly complains of a severe headache and neck stiffness and soreness and then begins to vomit. The nurse takes the client's blood pressure and notes that it is 210/102 mm Hg. On the basis of the findings, the nurse should obtain which medication from the emergency drawer of the medication cart?  Phentolamine 75) Acetylcysteine is prescribed for a client in the hospital emergency department after diagnosis of acetaminophen overdose. The nurse prepares to administer the medication using which procedure?  Diluting the medication in cola and administering it to the client orally 76) A pregnant client being admitted to the labor room tells the nurse that she felt a large gush of fluid before arriving at the hospital. The nurse performs an assessment on the client and notes that the fetal heart rate is 90 beats/minute and that the umbilical cord is protruding from the vagina. What is the appropriate nursing action?  Wrap the cord loosely in a sterile towel saturated with warm, sterile normal saline. 77) The nurse receives a telephone call from a neighbor, who states that her 3-year-old child was found sitting on the kitchen floor with an empty bottle of liquid furniture polish. The mother of the child tells the nurse that the bottle was half full, that the child's breath smells like the polish, and that spilled polish is present on the front of the child's shirt. What should the nurse tell the mother to do first?  Call the Poison Control Center. 78) The nurse is caring for a client who sustained multiple fractures in a motor vehicle crash 12 hours earlier. The client now exhibits severe dyspnea, tachycardia, and mental confusion, and the nurse suspects fat embolism. Which is the initial nursing action?  Position the client in a Fowler's position. 79) The home health nurse is visiting an older client whose family has gone out for the day. During the visit, the client experiences chest pain that is unrelieved by sublingual nitroglycerin tablets given by the nurse. Which action by the nurse would be appropriate at this time?  Call for an ambulance to transport the client to the hospital emergency department. 80) The client who has experienced a myocardial infarction (MI) is recovering from cardiogenic shock. The nurse knows that which observation of the client's clinical condition is most favorable?  Urine output of 40 mL/hr 81) A client in cardiogenic shock has a pulmonary artery catheter (Swan-Ganz type) placed. The nurse would interpret which cardiac output (CO) and pulmonary capillary wedge pressure (PCWP) readings as indicating that the client is most unstable?  CO 3 L/min, PCWP high 82) A client in cardiogenic shock had an intra-aortic balloon pump inserted 24 hours earlier via the left femoral approach. The nurse notes that the client's left foot is cool and mottled and the left pedal pulse is weak. Which action should the nurse take?  Call the health care provider immediately. 83) The nurse is caring for a client with a chest tube drainage system. While the client is being assisted to sit up in bed in preparation for ambulation, the chest tube accidentally disconnects from the chest drainage system. Which is the initial nursing action?  Place the end of the chest tube in a container of sterile water. 84) The nurse is caring for a client with a chest tube drainage system. During repositioning of the client, the chest tube accidentally pulls out of the pleural cavity. Which is the initial nursing action?  Apply an occlusive dressing. 85) The nurse reviewing the operative record for a client who has just undergone cardiac surgery notes that the client's cardiac output immediately after surgery was 3.6 L/min. Which intervention is appropriate based on the client's cardiac output reading?  Notify the health care provider (HCP). 86) The nurse has a prescription to administer acetylcysteine to a client admitted to the emergency department with acetaminophen overdose. Before giving this medication, what is the nurse's best action?  Empty the stomach by emesis or lavage. 87) A client with a history of gastric ulcer complains of a sudden, sharp, severe pain in the midepigastric area, which then spreads over the entire abdomen. The client's abdomen is rigid and boardlike on palpation, and the client obtains most comfort from lying in the knee-chest position. The nurse suspects which condition and should perform which action?  Perforation; notify the health care provider. 88) A postoperative client receives a dose of naloxone hydrochloride for respiratory depression shortly after transfer to the nursing unit from the postanesthesia care unit. After administration of the medication, the nurse should assess the client for which change?  Sudden increase in pain 89) A new nursing graduate is caring for a client who is attached to a cardiac monitor. While assisting the client with bathing, the nurse observes the sudden development of ventricular tachycardia (VT), but the client remains alert and oriented and has a pulse. Which interventions would the nurse take? Select all that apply.  Administer oxygen.  Obtain an electrocardiogram (ECG).  Contact the health care provider (HCP).  Assess circulation, airway, and breathing. 90) An emergency department nurse is caring for a child with suspected acute epiglottitis. Which nursing interventions apply in the care of this child? Select all that apply.  Ensure a patent airway.  Obtain a pediatric-size tracheostomy tray.  Prepare the child for a chest radiographic study.  Place the child on an oxygen saturation monitor. 91) A client with a left arm fracture supported in a cast complains of loss of sensation in the left fingers. The nursing assessment identifies pallor in the distal portion of the arm, poor capillary refill, and a diminished left radial pulse. On the basis of these findings, the nurse would take which as a priority action?  Contact the health care provider (HCP). 92) The nurse is caring for a client who is receiving feedings by nasogastric tube. The client suddenly begins to vomit, and the nurse quickly repositions the client. The client is coughing and having difficulty breathing. What is the nurse's priority action?  Suction the client. 93) A delivery room nurse is caring for a client in labor. The client tells the nurse that she feels that something is coming through the vagina. The nurse performs an assessment and notes the presence of the umbilical cord protruding from the vagina. The nurse should immediately place the client in which position?  On the side 94) The nurse witnesses an accident whereby a pedestrian is hit by an automobile. The nurse stops at the scene and assesses the victim. The nurse notes that the victim is responsive and has suffered trauma to the thorax resulting in a flail chest involving at least 3 ribs. What is the nurse's priority action for this victim?  Apply firm but gentle pressure with the hands to the flail segment. 95) The nurse is assessing a client hospitalized with acute pericarditis. The nurse monitors the client for cardiac tamponade, knowing that which signs are associated with this complication of pericarditis? Select all that apply.  Pulsus paradoxus  Distant heart sounds  Falling blood pressure (BP)  Distended jugular veins 96) A client has frequent runs of ventricular tachycardia. The health care provider has prescribed flecainide. What is the best nursing action related to the effects of this medication while the client is hospitalized?  Monitor vital signs and cardiac rhythm frequently. 97) A postpartum client with femoral thrombophlebitis has developed sudden shortness of breath and appears very anxious. What is the nurse's priority action for this client?  Administer oxygen by face mask as per protocol at 8 to 10 L/min. 98) The child with croup is being discharged from the hospital. The nurse provides instructions to the mother and advises the mother to bring the child to the emergency department if which occurs?  The child develops stridor. 99) The occupational health nurse is called to care for an employee who experienced a traumatic amputation of a finger. Which actions should the nurse take to provide emergency care and prepare the client for transport to the hospital? Select all that apply.  Elevate the extremity above heart level.  Assess the employee for airway or breathing problems.  Examine the amputation site and apply direct pressure to the site using layers of gauze. 100) An emergency department nurse is caring for a conscious child who was brought to the emergency department after the ingestion of half a bottle of acetylsalicylic acid (aspirin). The nurse anticipates that which will be the initial treatment?  The administration of an emetic 101) The nurse is providing care for a client with new onset of a dysrhythmia. The nurse anticipates which prescriptions from the health care provider? Select all that apply. Refer to Figure. View Figure  Oxygen therapy  An echocardiogram  An intravenous dose of metoprolol  A bolus of intravenous heparin followed by a continuous infusion 102) A depressed client is found unconscious on the floor in the dayroom of a health care facility. The nurse finds several empty bottles of a prescribed tricyclic antidepressant lying near the client. Which is the priority action of the nurse?  Call the emergency response team. 103) A client begins experiencing wheezing, anxiety, swelling, and hives after eating shellfish and is brought to the emergency department. Which immediate action should the nurse implement?  Maintain a patent airway. 104) The nurse prepares to administer acetylcysteine to the client with an overdose of acetaminophen. What is the appropriate action when administering this antidote?  Mix the medication in a flavored ice drink, and allow the client to drink the medication. 105) A client who has just suffered a large flail chest is experiencing severe pain and dyspnea. The client's central venous pressure (CVP) is rising, and the arterial blood pressure is falling. Which condition should the nurse interpret that the client is experiencing?  `Mediastinal flutter 106) A client develops atrial fibrillation with a ventricular rate of 140 beats/minute and signs of decreased cardiac output. Which medication should the nurse anticipate administering first?  Metoprolol 107) A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath and is visibly anxious. Which complication should the nurse immediately assess the client for?  Pulmonary embolism 108) A client with no history of respiratory disease is admitted to the hospital with respiratory failure. Which results on the arterial blood gas report that are consistent with this disorder should the nurse expect to note?  PaO2 49 mm Hg, PaCO2 52 mm Hg 109) The nurse in the labor room is performing an initial assessment on a newborn. The infant is exhibiting mild to moderate respiratory distress, audible bowel sounds in the chest, and a scaphoid abdomen. The infant is responding poorly to bag and mask ventilation. The nurse plans for which actions in the care of this infant? Select all that apply.  Notify the health care provider (HCP).  Prepare for endotracheal tube (ET) placement.  Insert an orogastric tube and connect it to low suction. 110) A child is admitted to the hospital after being seen in the emergency department with complaints of right lower quadrant abdominal pain, nausea and vomiting, fever, and chills. The health care provider (HCP) suspects appendicitis. Which assessment finding should the nurse immediately report to the HCP?  Sudden relief of abdominal pain 111) The mother of a 3-year-old boy calls the emergency department and states that she found an empty bottle of acetaminophen on the floor. She states that she thinks her child ingested all of the medication. What is the priority question for the nurse to ask the mother?  "Is your child breathing okay?" 112) A 5-year-old boy is brought by his mother to the emergency department after ingesting a bottle of acetylsalicylic acid. Which procedure should be initially instituted with this child?  Institute a gastric lavage and administer activated charcoal. 113) A mother brings her child to the emergency department. Based on the child's sitting position, drooling, and apparent respiratory distress, a diagnosis of epiglottitis is suspected. In anticipation of the health care provider's prescriptions, in which order of priority would the nurse implement the actions? Arrange the actions in the order that they should be performed. All options must be used.  1,2,3,4,5,6. 114) The nurse is caring for a client who has overdosed on phenobarbital. The nurse anticipates which assessment finding with this client?  Shallow respirations 115) The nurse is caring for a client who has overdosed on amphetamines. The nurse anticipates noting which assessment finding in this client?  Hypertension 116) A client experiencing cocaine toxicity is brought to the emergency department. The nurse should prepare to take which initial action?  Ensure a patent airway. 117) Which readings obtained from a client's pulmonary artery catheter suggest that the client is in left-sided heart failure?  Pulmonary capillary wedge pressure (PCWP) of 20 mm Hg 118) When creating a mechanically ventilated client's plan of care for prevention of ventilator-associated pneumonia (VAP), the nurse should include which measures in the plan? Select all that apply.  Suction the oral cavity whenever needed.  Practice frequent oral hygiene, including teeth brushing.  Wear gloves when suctioning or handling the endotracheal tube. 119) Which step should occur first when using an automated external defibrillator (AED)?  Apply defibrillator pads on the client. 120) Which should the nurse do when setting up an arterial line?  Tighten all tubing connections. 121) Which interventions would be included in the care of a client with a head injury and a subarachnoid bolt? Select all that apply.  Monitor vital signs.  Monitor neurological status.  Monitor the dressing for signs of infection.  Monitor for signs of increased intracranial pressure. 122) Which clinical manifestations of a tension pneumothorax should be of immediate concern to the nurse? Select all that apply.  Decreased cardiac output  Hyperresonance to percussion  Tracheal deviation to the opposite side 123) A client's arterial blood gas results reveal a PaO2 of 55 mm Hg. The client's admitting diagnosis is acute respiratory failure secondary to community-acquired pneumonia. What is the nurse's best action?  Notify the health care provider (HCP). 124) A client is admitted to the hospital for an acute episode of angina pectoris. Which parameter is the priority for the nurse to monitor?  Pulse and blood pressure 125) The nurse is caring for a client in the emergency department who has sustained a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing that this sequence is compatible with which most likely condition?  Epidural hematoma 126) The family of a client with a spinal cord injury rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic with a flushed face and neck and is complaining of a severe headache. The pulse rate is 40 beats/minute, and the blood pressure is 230/100 mm Hg. The nurse acts quickly, suspecting that the client is experiencing which condition?  Autonomic dysreflexia 127) A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, the nurse takes the following actions. Arrange the actions in the order they should be performed. All options must be used.  1) Raise the head of the bed.  2) Loosen tight clothing on the client.  3) Check for bladder distention.  4) Contact the health care provider (HCP).  5) Administer an antihypertensive medication.  6) Document the occurrence, treatment, and response. 128) A client is admitted to the hospital with a diagnosis of neurogenic shock after a traumatic motor vehicle collision. Which manifestation best characterizes this diagnosis?  Bradycardia 129) The nurse is performing a vaginal assessment of a pregnant woman who is in labor. The nurse notes that the umbilical cord is protruding from the vagina. The nurse would immediately take which action?  Exert upward pressure against the presenting part. 130) A client in the postpartum unit complains of sudden, sharp chest pain. The client is tachycardic, and the respiratory rate is increased. The health care provider diagnoses a pulmonary embolism. Which actions should the nurse plan to take? Select all that apply.  Administer oxygen.  Assess the blood pressure.  Start an intravenous (IV) line.  Prepare to administer morphine sulfate. 131) A client with angina pectoris is experiencing chest pain that radiates down the left arm. The nurse administers a sublingual nitroglycerin tablet to the client. The client's pain is unrelieved, and the nurse determines that the client needs another nitroglycerin tablet. Which vital sign is the most important for the nurse to check before administering the medication?  Blood pressure 132) A client whose cardiac rhythm was normal sinus rhythm suddenly exhibits a different rhythm on the monitor. The nurse should take which action? Refer to Figure. View Figure  Contact the health care provider (HCP). 133) The nurse is assisting in the care of a client who is being seen in the clinic with a suspected acetaminophen overdose. What is the nurse's priority of care?  Administer acetylcysteine. 134) A client who suffered carbon monoxide poisoning from working on an automobile in a closed garage has a carbon monoxide level of 15%. The nurse should anticipate observing which sign or symptom?  Flushing 135) A client presents to the urgent care center with complaints of abdominal pain and vomits bright red blood. Which is the priority nursing action?  Take the client's vital signs. 136) The nurse is admitting a young child who arrived from the emergency department after treatment for acetaminophen overdose. After administering the antidote, the nurse should reassess the child, including which priority laboratory value?  Liver function panel 137) The nurse is monitoring a child who is receiving ethylenediaminetetraacetic acid (EDTA) with BAL (British anti-Lewisite) for the treatment of lead poisoning. The nurse reviews the laboratory results for the child during treatment with this medication and is particularly concerned with monitoring which laboratory test result?  Blood urea nitrogen (BUN) level 138) The nurse is caring for a child who was burned in a house fire. The nurse develops a plan of care for monitoring the child during the treatment for burn shock. The nurse identifies which assessment as providing the most accurate guide to determine the adequacy of fluid resuscitation?  Level of consciousness 139) A 2-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering more than 40% of the body. The burns are both partial- and full-thickness burns. The nurse is asked to prepare for the arrival of the child and gathers supplies, anticipating that which treatment will be prescribed initially?  Insertion of a Foley catheter 140) A mother brings her child to the emergency department. Based on the child's sitting position, drooling, and apparent respiratory distress, a diagnosis of epiglottitis is suspected. The nurse should plan for which priority intervention?  Providing assisted ventilation and obtaining the necessary equipment 141) 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 apprehensive, complaining of a pounding headache, is dyspneic with chills, and has an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first?  Shut off the infusion. 142) When performing a surgical dressing change of a client's abdominal dressing, the nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. What should the nurse do next?  Apply a sterile dressing soaked with normal saline. 143) The nurse is caring for a client with a chest tube who accidentally disconnects the tube from the drainage system when trying to get out of bed. The nurse immerses the end of the tube in sterile water. What immediate action should the nurse take?  Obtain a new drainage system. 144) Which client situation is most appropriate for the nurse to consult with the Rapid Response Team (RRT)?  A 45-year-old client, 2 years after kidney transplant, second hospital day for treatment of pneumonia, no urine output for 6 hours, temperature 101.4°F (38.6°C), heart rate 98 beats/min, respirations 20 breaths/min, blood pressure 168/94 mm Hg 145) A client who attempted suicide by hanging is brought to the emergency department by emergency medical services. Which is the immediate nursing action?  Assess the client's respiratory status and for the presence of neck injuries. 146) The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride and needs to add the medication to the IV bag. The nurse should plan to take which action immediately after injecting the potassium chloride into the port of the IV bag?  Rotate the bag gently. 147) The nurse notes that the client's intravenous (IV) site is cool, pale, and swollen and that the solution is not infusing. What is the nurse's priority action?  Remove the IV catheter. 148) 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?  A backflash of blood is noted in the catheter. 149) The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse should document in the medical record that the client experienced which condition?  Phlebitis of the vein 150) 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. 151) 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? a. Sterile 2 × 2 gauze 152) A client 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. 153) 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?  5% dextrose in lactated Ringer's 154) The 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 instruction if the client makes which statement?  "I need to restrict my activity while this catheter is in place." 155) A client has just undergone insertion of a central venous catheter at the bedside. 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?  Portable chest x-ray film 156) A client with the recent diagnosis of myocardial infarction and impaired renal function is recuperating on the cardiac step-down unit. The client's blood pressure has been borderline low, and intravenous (IV) fluids have been infusing at 100 mL/hour via a central line catheter in the right internal jugular vein for approximately 24 hours to increase renal output and maintain the blood pressure. Upon entering the client's room, the nurse notes that the client is breathing rapidly and is coughing. The nurse determines that the client is most likely experiencing which complication of IV therapy?  Circulatory overload 157) The nurse in the hospital emergency department is preparing to administer fomepizole to a client with ethylene glycol (antifreeze) intoxication. The nurse should plan to administer this medication by which route?  Intravenous (IV) route 158) The emergency department nurse is preparing to administer fomepizole to a client suspected of ingesting antifreeze solution during a suicidal attempt. The nurse should prepare to administer this medication by which method?  Diluting the medication in 100 mL of 0.9% normal saline and administering it over 30 minutes 159) The emergency department nurse is preparing to administer fomepizole to a client suspected of having ethylene glycol (antifreeze) intoxication. The nurse obtains the vial of medication and notes that the medication has solidified. Which action should the nurse take?  Run the vial under warm water. 160) A client in shock is receiving dopamine hydrochloride by intravenous (IV) infusion. The nurse should have which medication available for local injection if IV infiltration and medication extravasation occur?  Phentolamine 161) A client admitted with hypertensive crisis has an intravenous (IV) infusion of 1000 mL of normal saline with 20 mEq of potassium chloride added. A prescription is written to administer sodium nitroprusside by continuous IV infusion. The nurse should plan to do which to administer this medication?  Protect the sodium nitroprusside from light with an opaque material. 162) The nurse has a new prescription to administer verapamil by the intravenous (IV) route. In administering this medication, the most important nursing action should be to use what item to monitor the client's response to the medication?  A cardiac monitor 163) A client with rapid-rate atrial fibrillation has a new prescription for diltiazem hydrochloride by intravenous (IV) bolus followed by a continuous IV infusion of the same medication. What should the nurse plan for with the administration of this medication?  Discontinuing the infusion after 24 hours 164) A client being admitted to the coronary care unit from the emergency department has a stat prescription to receive a dose of intravenous procainamide followed by a continuous infusion. Based on this prescription, the nurse should assess for which condition?  Ventricular ectopy 165) The nurse has a prescription to give amiodarone intravenously to a client. What is the priority assessment during administration of this medication?  Cardiac rhythm 166) The nurse is caring for a client with a diagnosis of myocardial infarction (MI). The client is experiencing chest pain that is unrelieved by the administration of nitroglycerin. The nurse administers morphine sulfate to the client as prescribed by the health care provider. After administration of the morphine sulfate, what is the priority assessment?  Respirations 167) A client hospitalized with a diagnosis of myocardial infarction calls for the unit nurse because the client is experiencing chest pain. The nurse administers a sublingual nitroglycerin tablet as prescribed. The client, who is receiving oxygen by nasal cannula, reports that her chest pain is unrelieved by the nitroglycerin. Which is the next nursing action for this client?  Administer another nitroglycerin tablet. 168) A client is diagnosed with atrial fibrillation, and the health care provider prescribes medication therapy. Prior to initiating medication therapy, which cardiac rhythm would the nurse expect to note on the cardiac monitor? Click on the image to indicate your answer.  Indication: ✓ 169) A client is admitted to the hospital with a diagnosis of myocardial infarction (MI) and is going to have an intravenous (IV) nitroglycerin infusion started. Noting that the client does not have an intra-arterial monitoring line in place, what piece of equipment should the nurse obtain for use at the bedside?  Noninvasive blood pressure monitor 170) A client returning to the nursing unit after a cardiac catheterization procedure has a stat prescription to receive a dose of intravenous procainamide. Which piece of equipment would be most appropriate for the nurse to use in determining the client's response to this medication?  Cardiac monitor 171) A client with heart failure and hypotension has been started on intravenous medication therapy with inamrinone. The nurse determines which finding, if noted in the client, is an adverse effect of the medication?  Decreased blood pressure 172) A client sustained a burn injury at 7:00 a.m. The client's spouse states that before the burn, the client's body weight was 198 lbs. The health care provider has estimated that the total body surface area (BSA) burned is 83%. Using the Parkland (Baxter) formula (4 mL × kilograms of body mass × percent total BSA), the nurse determines that the total amount of intravenous lactated Ringer's solution that the client will receive by 3 p.m. of the same day on which the burn occurred is which value? Fill in the blank.  14,940 mL 173) A client has a closed head injury with increased intracranial pressure (ICP). The increased ICP is being managed by mannitol 25 g by the intravenous (IV) route every 2 hours. The nurse is planning to administer this medication via IV pump in what manner?  Giving it slowly over 30 to 90 minutes 174) The nurse is administering lidocaine hydrochloride by the intravenous route. Which finding(s) should the nurse report to the health care provider immediately?  Client complaints of blurred vision and nausea 175) The nurse is caring for a client with acute pulmonary edema. The health care provider (HCP) tells the nurse that medication will be prescribed to help reduce preload and afterload. Based on the HCP's statement, what medication should the nurse anticipate administering?  Nitroprusside sodium 176) A client is scheduled for placement of a peripherally inserted central catheter (PICC). The nurse has explained the advantages of this catheter to the client. Which statement made by the client indicates a need for further explanation?  "It is specifically designed for short-term use." 177) The nurse in the hospital emergency department is caring for a client with suspected opioid overdose and is preparing to administer the reversal agent via the intravenous route. Which statement is correct about the administration of this medication?  After the initial dose, prepare to administer additional intravenous doses if needed. 178) The nurse is obtaining blood from a client's double-lumen central venous catheter for blood cultures. Which actions are correct for performing this procedure? Select all that apply.  Turn the infusion off for at least 1 minute before obtaining the specimen.  Use the initial specimen of blood obtained from the catheter for the blood cultures. 179) A client has an epidural catheter in place after colon surgery and is receiving pain medication through the catheter. During the night the client calls the nurse and says, "I have a terrible headache that just started now." The nurse checks the epidural catheter insertion site and notes a small amount of clear drainage leaking from the bandage. What is the first action the nurse should take?  Stop the infusion. 180) 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?  Infiltration 181) A client with total parenteral nutrition (TPN) 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 182) 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. 183) A client is receiving total parenteral nutrition (TPN). The nurse monitors the client for complications of the therapy and should assess the client for which manifestations of hyperglycemia?  Weakness, thirst, and increased urine output 184) A client has been discharged to home on total parenteral nutrition (TPN). With each visit, the home care nurse should assess which parameters most closely in monitoring this therapy?  Temperature and weight 185) The nurse is performing an assessment on a client who has been receiving total parenteral nutrition (TPN) at 125 mL/hour. On assessment, the nurse notes the presence of bilateral crackles in the lungs and 2+ pedal edema. The nurse also notes that the client has gained 3 pounds (1.5 kg) in 5 days. Which nursing action would be most appropriate for this client?  Notify the health care provider (HCP) of the assessment findings. 186) The nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a central line. Which nursing intervention would specifically provide assessment data related to the most common complication associated with TPN?  Monitoring the temperatu 187) The nurse is creating a plan of care for a client who is receiving total parenteral nutrition (TPN). Which assessment should be included in the plan of care?  Blood glucose levels every 6 hours 188) Fat emulsion is prescribed for the client receiving total parenteral nutrition. The nurse is preparing to administer the fat emulsion and notes the presence of fat globules in the solution. What should the nurse do?  Return the solution to the pharmacy. 189) A client receiving total parenteral nutrition (TPN) experiences sudden development of chest pain, dyspnea, tachycardia, cyanosis, and a decreased level of consciousness. What should the nurse suspect as a complication of the TPN?  Air embolism 190) A client receiving total parenteral nutrition (TPN) through a single-lumen central intravenous (IV) line is scheduled to receive an antibiotic by the IV route. Which action by the nurse is appropriate before hanging the antibiotic solution?  Ensure a separate IV access for the antibiotic. 191) The nurse notes that a client's total parenteral nutrition (TPN) solution is 4 hours behind. Which action should the nurse take?  Assess the infusion pump to be sure it is functioning properly and is set at the correct rate. 192) A client receiving total parenteral nutrition (TPN) is demonstrating signs and symptoms of an air embolism. What is the first action by the nurse?  Place the client on the left side in the Trendelenburg's position. 193) The nurse is preparing to administer lipid emulsion to a client who has just been started on total parenteral nutrition. Before administering the lipid emulsion, the nurse asks the client about allergies. The nurse should withhold the lipid emulsion and contact the health care provider if the client identifies an allergy to which food item?  Soybean oil 194) The nurse notes redness, warmth, and a yellowish drainage at the insertion site of a central venous catheter in a client receiving total parenteral nutrition. What is the nurse's initial action?  Evaluate for signs of septicemia. 195) A client with cancer is placed on permanent total parenteral nutrition (TPN). The nurse considers psychosocial support when planning care for this client when the client makes which correct statement?  "I'll need to adjust to the idea of living without eating by the usual route." 196) The nurse is assigned to a client receiving total parenteral nutrition (TPN) who had a blood glucose measurement done at 06:00. The nurse documents on the client's clinical worksheet for the day that the blood glucose level should be checked next at which time?  12:00 197) The home care nurse is monitoring a client's response to total parenteral nutrition (TPN). The client's weight 1 week earlier was 114 lbs (52 kg). The nurse determines that the client is gaining weight as expected if which morning weight is noted?  116 lbs (52.6 kg) 198) What electrolytes and amounts are usually contained in total parenteral nutrition (TPN) for an adult client without renal or hepatic impairment? Select all that apply.  Sodium 1 to 2 mEq/kg  Magnesium 8 to 20 mEq  Potassium 1 to 2 mEq/kg  Phosphate 20 to 40 mmol 199) A client who has been receiving total parenteral nutrition (TPN) by way of a central venous access device complains of shakiness and is diaphoretic. Based on these findings, the nurse should perform which assessment next?  Blood glucose level 200) A client with pancreatitis is being weaned from total parenteral nutrition (TPN). The client asks the nurse why the TPN cannot just be stopped. What is the nurse's best response?  Rebound hypoglycemia is a risk. 201) The nurse hears that a client receiving total parenteral nutrition (TPN) at 100 mL/hr has bilateral crackles and 1+ pedal edema during shift report. When the nurse obtains a daily weight, the nurse notes that the client has gained 4 lbs (1.8 kg) in 2 days. Which action should the nurse take first?  Compare the intake and output records of the past 2 days. 202) The nurse is caring for a client receiving total parenteral nutrition (TPN) via a central line. What assessment should the nurse perform to detect the most common complication of TPN?  Vital signs 203) The community health nurse is providing an educational session to a group of community members regarding the issue of organ donation. A member of the group asks the nurse, "How old does someone have to be to provide consent for organ donation?" Which response should the nurse make?  "A donor must be 18 years of age or older to provide consent." 204) The nurse is caring for a client with terminal cancer who is close to death. On reviewing the plan of care, the nurse determines that which intervention is the priority?  Maintain the client's dignity and self-esteem, and make the client as comfortable as possible. 205) A client brought to the emergency department is dead on arrival (DOA). The family of the client tells the health care provider (HCP) that the client had terminal cancer. The HCP examines the client and asks the nurse to contact the medical examiner regarding an autopsy. Family members of the client tell the nurse that they do not want an autopsy performed. Which response to the family is appropriate?  "I will contact the medical examiner regarding your request." 206) The nurse is caring for a client with cancer. The client tells the nurse that a lawyer will be arriving today to prepare a living will and asks the nurse to act as one of the witnesses for the will. What is the most appropriate nursing action?  Ask the client who might be available to serve as a witness. 207) The nurse is monitoring ongoing care for a potential organ donor who has been diagnosed with brain death. Which finding indicates to the nurse that the standard for ongoing care has been maintained?  Urine output 100 mL/hr 208) A client who suffered a severe head injury has had vigorous treatment to control cerebral edema. Brain death has been determined. The nurse prepares to carry out which measure to maintain viability of the kidneys before organ donation?  Administering intravenous (IV) fluids 209) Which interventions should the nurse take for a deceased client whose eyes will be donated? Select all that apply.  Close the client's eyes.  Elevate the head of the bed.  Place wet saline gauze pads and a cool pack on the eyes. 210) The nurse is preparing a plan of care for a client who just delivered a dead fetus. Which initial action should the nurse include in the client's plan of care to meet the emotional needs of the client and spouse?  Assess the client's and the spouse's perception of the event. [Show More]

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