Saunders Comprehensive NCLEX Review Questions and

Saunders Comprehensive NCLEX Review Questions and Answers (5th Ed.) 2023

• 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 - ANSWER 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 - ANSWER 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 - ANSWER 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 - ANSWER 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." - ANSWER 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. - ANSWER

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 - ANSWER 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 - ANSWER 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 - ANSWER b