Saunders Comprehensive Review for the NCLEX-PN

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NCLEX-PN

Teacher 179 terms angiepowell8989 Preview NCLEX 125 term Bro The nurse has received the client assignment for the day.Which client would the nurse attend to 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 of 50 mg/dL and

complains of blurred vision.

Correct Answer: D. The client who has a blood glucose of 50 mg/dL and

complains of blurred vision.The client has a low blood glucose level and symptoms reflective of hypoglycemia. This client would be attended to first so that treatment can be implemented. Although the other clients have needs that require attention, they are not the priority and can wait until the client in option 4 is stabilized.The 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 would assemble which 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

Correct Answer: C. Gloves, mask, gown, and goggles

Splashes of infective material can occur during wound irrigation or suctioning of the tracheostomy.

The nurse is choosing age-appropriate toys for a toddler.Which toy is the best choice for this age?

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

Correct Answer: C. Large stacking blocks

This question addresses the Client Needs category Health Promotion and Maintenance and specifically relates to the principals of growth and development of a toddler. Not the strategic word best. Toddlers like to master activities independently, such as stacking blocks. Because toddlers do not have the developmental ability to determine what would 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 client statement indicates an understanding of this stress reduction measure?

• "This will help only if I play music at the same time."
• "This will work for me only if I am alone in a quiet area."
• "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." Correct Answer: D. "The best thing about tis is that I can use it anywhere, anytime." This question addresses the Client Needs category Psychosocial Integrity and the content addresses coping mechanisms. Focus on the subject, client understanding of guided imagery. Guided imagery involves the client creating 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 would 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.

Correct Answer: Consciously think about walking over imaginary lines on the

floor.This question addresses the subcategory Basic Care and Comfort in the Client Needs category Physiological Integrity and addresses client mobility and promoting assistance in an activity of daily living to maintain safety. Focus on the subject, a suggestion that will ensure client 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 walk over can keep them moving forward while remaining safe.The nurse monitors a client receiving digoxin for which early manifestation of digoxin toxicity?

• Anorexia
• Facial pain
• Photophobia
• Yellow color perception.

Correct Answer: A. Anorexia

This question addresses the subcategory Pharmacological Therapies in the Client Needs category Physiological Integrity. Note the strategic word, early. 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, diplopia, 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 would implement which action to prepare the client for this test?

• Shave the groin for insertion of a femoral catheter.
• Remove all metal-containing objects from the client.
• Keep the client NPO for 6 hours before the test.
• Instruct the client in inhalation techniques for the

administration of the radioisotope.

Correct Answer: B. Remove all metal-containing objects from the client.

This question addresses the subcategory, Reduction of Risk potential, in the Client Needs category Physiological Integrity, and the nurse's responsibilities in preparing the client for the diagnostic test. Focus on the subject, preparation for an MRI. In an MRI study, radiofrequency pulses in a magnetic field are converted into pictures. All metal objects, such as rings, bracelets, hairpins, and watches, would be removed. In addition, a history would be taken to ascertain whether the client has any internal metallic devices, such as orthopedic hardware, pacemakers, or shrapnel. NPO status is not necessary for an MRI study of the head. The groin may be shaved fr an angiogram, and inhalation of the radioisotope may be prescribed with other types of scans but is not part of the procedures for an MRI.A client with renal insufficiency has a magnesium level of 3.5 mEq/L. On the basis of this laboratory result, the nurse interprets which sign as significant?

• Hyperpnea
• Drowsiness
• Hypertension
• Physical hyperactivity

Correct Answer: B. Drowsiness

This question addresses the subcategory Physiological Adaptation, in the Client Needs category Physiological Integrity. Determine whether an abnormality exists.The laboratory value noted in the question addresses an alteration in body systems. The normal magnesium level is 1.8 to 2.6 mEq/L. A magnesium level of 3.5 mEq/L indicates hypermagnesemia. Neurological manifestations 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 make me worse 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 your doctor."

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

that everything will be okay." Correct Answer: A. "Can you tell me what you understand about the procedure." This question addresses the subcategory, Caring, in the category Integrated Processes. The correct option 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 toward the doctor's importance.Option 4 does not address the client's fears, provides false reassurance, and puts the client's feelings on hold.

A prescription reads: acetaminophen liquid, 650 mg

orally every 4 hours PRN for pain. The medication label

reads: 500 mg/15 mL. The nurse prepares how many

milliliters to administer one dose?

• 19 mL
• 20 mL
• 19.5 mL
• 18.5 mL

Correct Answer: 19.5 mL

(Dosage/available) x volume = mL Note the data in the question, then use the formula for calculating a medication dose. Once the dose is determined, you will need to type your numeric answer in the box. Always follow the specific directions noted on the computer screen.Also, remember that there will be an on-screen calculator available for your use.

The emergency department nurse is caring for a child suspected of acute epiglottis. 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

A. 5, 2, 6, 3, 4, 1

B. 2, 3, 5, 6

C. 2, 3, 6, 5

D. 2, 6, 5, 1

Correct Answer: B. 2, 3, 5, 6

In a multiple response question, you will be asked to select or check all of the options, such as interventions that relate to the data in the question. To answer this question, recall that acute epiglottis is a serious obstructive inflammatory process that requires immediate intervention and that airway patency is a priority.Examination of the throat with a tongue depressor or attempting to obtain a throat culture is contraindicated because the examination can precipitate further obstruction. A lateral neck and chest x-ray is obtained to determine the degree of obstruction, if present. To reduce respiratory distress, the child would sit upright.The child is placed on an oxygen saturation monitor to monitor oxygenation status. Tracheostomy and intubation may be necessary if respiratory distress is severe. Remember to follow the specific directions given on the computer screen and for this question, select all that apply.Electrocardiogram shows irregular heartbeats with variation in the frequency.A client who experienced a myocardial infarction is being monitored via cardiac telemetry. The nurse notes the sudden onset of a coarse ventricular fibrillation (VF) cardiac rhythm on the monitor and would plan to take which immediate action?

• Take the client's blood pressure.
• Initiate cardiopulmonary resuscitation (CPR)
• Place a nitroglycerin tablet under the client's tongue.
• Continue to monitor the client and then contact the

primary health care provider (PHCP.)

Correct Answer: B. Initiate cardiopulmonary resuscitation (CPR)

The goals of treatment are to terminate ventricular fibrillation (VF) promptly and to convert it to an organized rhythm. The PHCP or an Advanced Cardiac Life support (ACLS)-qualified nurse must immediately defibrillate the client. If a defibrillator is not readily available, CPR is initiated until the defibrillator arrives.Options 1, 3, and 4 are incorrect actions and delay life-saving treatment.The nurse reviews the history and physical examination documented in the medical record of a client requesting a prescription for oral contraceptives. The client has renal calculi, had thrombophlebitis 1 year ago, takes a daily multivitamin orally, and a normal electrocardiogram. The nurse determines that oral contraceptives are contraindicated because of which of these documented items?

• Renal calculi
• Thrombophlebitis
• Takes a daily multivitamin
• Electrocardiogram results

Correct Answer: B. Thrombophlebitis

Oral contraceptives are contraindicated in women with a history of any of the

following: thrombophlebitis and thromboembolic disorders, cardiovascular or

cerebrovascular diseases (including stroke), any estrogen-dependent cancer or breast cancer, benign or malignant liver tumors, impaired liver function, hypertension, and diabetes mellitus with vascular involvement. Adverse effects of oral contraceptives include increased risk of superficial and deep venous thrombosis, pulmonary embolism, thrombotic stroke (or other types of strokes), myocardial infarction, and accelerations of preexisting breast tumors.