Saunders Comprehensive NCLEX Review Questions (5th Ed.)

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• A nurse notes blanching, coolness, and edema at the

peripheral intravenous (IV) site. Based on these findings, the nurse implements which action?

• Discontinues the IV
• Applies a warm compress
• Checks for a blood return
• Measures the area of infiltration

a (This question requires that you focus on the data identified in the question and determine that the client is experiencing an infiltration. Next you need to consider the harmful effects of infiltration and determine the action to implement. Because infiltration can be damaging to the surrounding tissue, the most appropriate action is to discontinue the IV to prevent any further damage.)

• A nurse has received the client assignment for the day.

Which client should the nurse assess first?

• The client who has a nasogastric tube attached to

intermittent suction

• The client who needs to receive subcutaneous insulin

before breakfast

• The client who is 2 days postoperative and is

complaining of incisional pain

• The client who has a blood glucose level of 50 mg/dL

and complaints of blurred vision d (This question requires you to establish priorities by comparing the needs of each client and deciding which need is urgent. The client described in option 4 has a blood glucose level and symptoms reflective of hypoglycemia. This client should be assessed first so that treatment can be implemented. Although the clients in options 1, 2, and 3 have needs that require assessment, they are not a priority and can wait until the client in option 4 is stabilized.)

• A nurse prepares to care for a client on contact

precautions who has a hospital-acquired infection caused by methicillin-resistant Staphylococcus aureus (MRSA).The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator, which requires frequent suctioning.The nurse assembles which of the following necessary protective items before entering the client's room?

• Gloves and a gown
• Gloves, mask, and goggles
• Gloves, mask, gown, and goggles
• Gloves, gown, and shoe protectors

c (This question addresses content related to protecting oneself from contracting an infection and requires that you consider the methods of possible transmission of infection, based on the client's condition. Because splashes of infective material can occur during the wound irrigation or suctioning of the tracheostomy, option 3 is correct.)

• The nurse is choosing age-appropriate toys for a

toddler. Which of the following would be the best toy?

• Puzzle
• Toy soldiers
• Large stacking blocks
• A card game with large pictures

c (Toddlers like to master activities independently, such as stacking blocks. Because toddlers do not have the developmental ability to determine what could be harmful, toys that are safe need to be provided. A puzzle and toy soldiers provide objects that can be placed in the mouth and may be harmful for a toddler. A card game with large pictures may require cooperative play, which is more appropriate for a school-age child.)

• A client with coronary artery disease has selected

guided imagery to help cope with psychological stress.Which of the following statements indicates the client's understanding of this stress reduction measure?

• "This will work for me only if I am alone in a quiet area."
• "This will help only if I play music at the same time."
• "I need to do this only when I lie down in case I fall

asleep."

• "The best thing about this is that I can use it anywhere,

anytime." d (Guided imagery involves the client's creation of an image in the mind, concentrating on the image, and gradually becoming less aware of the offending stimulus. It can be done anytime and anywhere; some clients may use other relaxation techniques or play music with it.)

• A client with Parkinson's disease develops akinesia

while ambulating, increasing the risk for falls. Which suggestion should the nurse provide to the client to alleviate this problem?

• Use a wheelchair to move around.
• Stand erect and use a cane to ambulate.
• Keep the feet close together while ambulating and use

a walker.

• Consciously think about walking over imaginary lines

on the floor.d (This question addresses client mobility and promoting assistance in an activity of daily living to maintain safety. Clients with Parkinson's disease can develop bradykinesia (slow movement) or akinesia (freezing or no movement). Having these clients imagine lines on the floor to step over can keep them moving forward while remaining safe.)

• The nurse monitors a client receiving digoxin (Lanoxin)

for which early manifestation of digoxin toxicity?

• Anorexia
• Facial pain
• Photophobia
• Yellow color perception

a (Digoxin is a cardiac glycoside that is used to manage and treat heart failure and to control ventricular rates in clients with atrial fibrillation. The most common early manifestations of toxicity include gastrointestinal disturbances such as anorexia, nausea, and vomiting. Neurological abnormalities can also occur early and include fatigue, headache, depression, weakness, drowsiness, confusion, and nightmares. Facial pain, personality changes, and ocular disturbances (photophobia, light flashes, halos around bright objects, yellow or green color perception) are also signs of toxicity, but are not early signs.)

• A magnetic resonance imaging (MRI) study is

prescribed for a client with a suspected brain tumor. The nurse implements which action to prepare the client for this test?

• Keeps the client NPO for 6 hours before the test
• Shaves the groin for insertion of a femoral catheter
• Removes all metal-containing objects from the client
• Instructs the client in inhalation techniques for the

administration of the radioisotope c (This question addresses the nurse's responsibilities in preparing the client for the diagnostic test. In an MRI study, radiofrequency pulses in a magnetic field are converted into pictures. All metal objects, such as rings, bracelets, hairpins, and watches, should be removed. In addition, a history should be taken to ascertain whether the client has any internal metallic devices, such as orthopedic hardware, pacemakers, or shrapnel. For an abdominal MRI study, the client is usually NPO.NPO status is not necessary for an MRI study of the head. The groin may be shaved for an angiogram, and inhalation of the radioisotope may be prescribed with a positron emission tomography (PET) scan or ventilation/perfusion lung scan.)

• A client with renal insufficiency has a magnesium level

of 3.6 mg/dL. Based on this laboratory result, the nurse interprets which of the following signs as significant?

• Hyperpnea
• Drowsiness
• Hypertension
• Physical hyperactivity

b (This question addresses an alteration in body systems. The normal magnesium level is 1.6 to 2.6 mg/dL. A magnesium level of 3.6 mg/dL indicates hypermagnesemia. Neurological manifestations begin to occur when magnesium levels are elevated and are noted as symptoms of neurological depression, such as drowsiness, sedation, lethargy, respiratory depression, muscle weakness, and areflexia. Bradycardia and hypotension also occur.)

• A client is scheduled for angioplasty. The client says to

the nurse, "I'm so afraid that it will hurt and will make me worse off than I am." Which response by the nurse is therapeutic?

• "Can you tell me what you understand about the

procedure?"

• "Your fears are a sign that you really should have this

procedure."

• "Try not to worry. This is a well-known and easy

procedure for the doctor."

• "Those are very normal fears, but please be assured

that everything will be okay." a (Option 1 is a therapeutic communication technique that explores the client's feelings, determines the level of client understanding about the procedure, and displays caring. Option 2 demeans the client and does not encourage further sharing by the client. Option 3 diminishes the client's feelings by directing attention away from the client and to the physician's importance. Option 4 does not address the client's fears and puts the client's feelings on hold.)

• An emergency department nurse is caring for a child

suspected of acute epiglottitis. Which interventions apply in the care of the child? Select all that apply.

• Obtain a throat culture.
• Ensure a patent airway.
• Prepare the child for a chest x-ray.
• Maintain the child in a supine position.
• Obtain a pediatric-size tracheostomy tray.
• Place the child on an oxygen saturation monitor.

b, c, e, f (Recall that acute epiglottitis is a serious obstructive inflammatory process that requires immediate intervention. To reduce respiratory distress, the child should sit upright. Examination of the throat with a tongue depressor or attempting to obtain a throat culture is contraindicated because the examination can precipitate further obstruction. The child is placed on an oxygen saturation monitor to monitor oxygenation status. A lateral neck and chest x-ray is obtained to determine the degree of obstruction, if present. Tracheostomy and intubation may be necessary if respiratory distress is severe. Remember to follow the specific directions given on the computer screen.)

• A nurse is caring for a hospitalized client with a

diagnosis of congestive heart failure who suddenly complains of shortness of breath and dyspnea. The nurse takes which immediate action?

• Calls the physician
• Administers oxygen to the client
• Elevates the head of the client's bed
• Prepares to administer furosemide (Lasix)

c (Now you may immediately think the client has developed pulmonary edema, a complication of congestive heart failure, and needs a diuretic. Although pulmonary edema is a complication of congestive heart failure, there is no information in the question that indicates the presence of pulmonary edema. The question simply states that the client suddenly complains of shortness of breath and dyspnea. Read the question carefully. Note the strategic word immediate and focus on the subject: the client's complaints. Although the physician may need to be notified, this is not the immediate action. A physician's prescription is needed to administer oxygen. Furosemide is a diuretic and may or may not be prescribed for the client. Because there is no information in the question that indicates the presence of pulmonary edema, option 3 is correct. The question is asking you for a nursing action, so that is what you need to look for as you eliminate the incorrect options.)