NURS 215 NCLEX review Comprehensive

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NURS 215 NCLEX review Comprehensive exam EVOLVE Graded A+ Guaranteed success latest Updated 2022-2023. 1 / 4

1.ID: 383711499

Enalapril maleate (Vasotec) is prescribed for a hospitalized client. Which assessment does the nurse perform as a priority before administering the medication?

Checking the client's blood pressure Correct Checking the client's peripheral pulses Checking the most recent potassium level Checking the client's intake-and-output record for the last 24 hours

A client is scheduled to undergo an upper gastrointestinal (GI) series, and the nurse provides instructions to the client about the test. Which statement by the client indicates a need for further instruction?

"The test will take about 30 minutes."

"I need to fast for 8 hours before the test."

"I need to drink citrate of magnesia the night before the test and give myself a Fleet enema on the morning of the test." Correct

"I need to take a laxative after the test is completed, because the liquid that I’ll have to drink for the test can be constipating." A nurse on the evening shift checks a physician's prescriptions and notes that the dose of a prescribed medication is higher than the normal dose. The nurse calls the physician's answering service and is told that the physician is of for the night and will be available in the morning. The nurse should:

Call the nursing supervisor

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Ask the answering service to contact the on-call physician Correct Withhold the medication until the physician can be reached in the morning Administer the medication but consult the physician when he becomes available An emergency department (ED) nurse is monitoring a client with suspected acute myocardial infarction (MI) who is awaiting transfer to the coronary intensive care unit. The nurse notes the sudden onset of premature ventricular contractions (PVCs) on the monitor, checks the client's carotid pulse, and determines that the PVCs are not resulting in perfusion. The appropriate action by the nurse is:

Documenting the findings

Asking the ED physician to check the client Correct Continuing to monitor the client's cardiac status

Informing the client that PVCs are expected after an MI NPO status is imposed 8 hours before the procedure on a client scheduled to undergo electroconvulsive therapy (ECT) at 1 p.m. On the morning of the procedure, the nurse checks the client's record and notes that the client routinely takes an oral antihypertensive medication each morning. The nurse should:

Administer the antihypertensive with a small sip of water Correct Withhold the antihypertensive and administer it at bedtime

Administer the medication by way of the intravenous (IV) route Hold the antihypertensive and resume its administration on the day after the ECT A client who recently underwent coronary artery bypass graft surgery comes to the physician's office for a follow-up visit. On assessment, the client tells the nurse that he is feeling depressed. Which response by the nurse is therapeutic?

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"Tell me more about what you’re feeling." Correct "That’s a normal response after this type of surgery." "It will take time, but, I promise you, you will get over this depression."

"Every client who has this surgery feels the same way for about a month." A client in labor experiences spontaneous rupture of the membranes. The nurse immediately counts the fetal heart rate (FHR) for 1 full minute and then checks the amniotic fluid. The nurse notes that the fluid is yellow and has a strong odor. Which of the following actions should be the nurse’s priority?

Contacting the physician Correct

Documenting the findings Checking the fluid for protein

Continuing to monitor the client and the FHR

A nurse has assisted a physician in inserting a central venous access device into a client with a diagnosis of severe malnutrition who will be receiving parenteral nutrition (PN). After insertion of the catheter, the

nurse immediately plans to:

Call the radiography department to obtain a chest x-ray Correct

Check the client's blood glucose level to serve as a baseline measurement Hang the prescribed bag of PN and start the infusion at the prescribed rate

Infuse normal saline solution through the catheter at a rate of 100 mL/hr to maintain patency

A rape victim being treated in the emergency department says to the nurse, "I’m really worried that I’ve got HIV now." What is the appropriate response by the nurse?

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