Saunders Med-Surge RN-NCLEX 500 QUESTIONS SET OF 5 OF 5

Saunders Med-Surge RN-NCLEX 500 QUESTIONS SET OF 5 OF 5 Saunders Nclex -RN question 100 set of 1 of 5

• An older client has been lying in a supine position for the past 3 hours. The nurse who is

repositioning this client would be most concerned with examining which bony prominences of the client? Select all that apply.

Missed one answer: Heels, elbows, Ankles, sacrum and back of head

What I learned from being wound care nurse is, lying on your back facing the ceiling the back of the head, heels, ankles, trochanter, sacrum, back and scapulae are all boney areas that are at greater risk for pressure sores to develop. The patient needs to be turned every two hours to elevated the weight on each side of the body.

• The nurse is reviewing the arterial blood gas values of a client and notes that the pH is 7.31

(7.31), Paco2 is 50 mm Hg (50 mm Hg), and the bicarbonate (HCO3) level is 26 mEq/L (26 mmol/L). The nurse concludes that which acid-base disturbance is present in this client?

Correct answer: Respiratory acidosis

With respiratory acidosis, pH is decreased and Paco2 level increased. Respiratory alkalosis, pH elevated and Paco2 decrease.

• 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?

Correct answer: Position the infant flat on his or her right side.

Worsening respiratory distress, bowel sounds in chest, lay baby flat on right side, flat or scaphoid abdomen are all signs and symptoms of a congenital diaphragmatic hernia. Need order for x- rays. Baby will need to be NPO, and need ventilation to help with breathing.57 A client with severe back pain and hematuria is found to have hydronephrosis due to urolithiasis. The nurse anticipates which treatment will be done to relieve the obstruction?

Correct answer: insertion of a nephrostomy tube

Urolithiasis occurs when a stone forms in urinary system. Hydronephrosis develops when the stone has blocked the ureter and urine backs up and dilates and damages the kidney. Treatment allow urine to drain and relieve the obstruction in the ureter. PD is not needed cause kidney is functioning. Opioid analgesics are necessary for pain relief but do not treat the obstruction.64 The nurse is evaluating fluid resuscitation attempts in the burn client. Which finding indicates adequate fluid resuscitation?

Correct answer: Heart rate of 95 beats/minute

Adequacy of fluid volume resuscitation can be evaluated by determining if urine output is at least 30 mL/hour, peripheral pulses are +2 or better, and the client is oriented to client, place, heart rate less than 120 beats/min and time.70 A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis?

Missed one answer: Diarrhea

Grayish-blue discoloration at the flank is known as Grey-Turner's sign and occurs as a result of pancreatic enzyme leakage to cutaneous tissue from the peritoneal cavity. My have pain all of sudden the in stomach, may have tenderness with palpation.

• The nurse is providing morning care to a client who has a closed chest tube drainage system

to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. The nurse immediately applies sterile gauze over the chest tube insertion site. Which is the nurse's next action?

Correct answer: Replace the chest tube system.

When it comes dislodged from the insertion site, I would immediately applies sterile gauze over the site and call the HCP. I would keep the client in upright position. May attached new chest tube if requires insertion, may not be in this order. Check pulse oximetry readings for oxygen level for respiratory status.

• A client who has had a total knee arthroplasty tells the nurse that there is pain with extension

of the knee. The nurse should perform which action?

Correct answer: Notify the health care provider.

Extension pain is a common complaint of clients after knee arthroplasty, nurse should encourage the client to keep the knee extended and administer analgesics as needed.

• The nurse provides instructions to a client with bilateral deformities of the joints of the

fingers due to rheumatoid arthritis. When providing teaching about the disease process, the nurse should inform the client that the changes are most likely due to what type of response?

Correct answer: Autoimmune

Most likely cause for rheumatoid arthritis is activation of an autoimmune response. Thought to trigger antigen-antibody responses and release of lysosomes from phagocytic cells, which ultimately attack the cartilage and synovia, with resultant synovitis.

• A health care provider prescribes 1 unit of packed red blood cells to be infused over 4 hours.

The unit of blood contains 250 mL. The drop factor is 15 drops (gtt)/mL. The nurse should set the flow rate at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number.

Correct answer: 16gtt/min

250mlx15gtt=3750/240=15.62 round up 16gtt

Saunders Nclex -RN question 100 set of 2 of 5

• The nurse has given the client instructions about crutch safety. Which statement indicates that

the client understands the instructions? Select all that apply.

Correct answer:

I should not use someone else's crutches I need to remove any scatter rugs at home I need to have spare crutches and tips available Use only crutches measured for the client, When assessing the home for safety, the nurse ensures client knows to remove any scatter rugs and don’t walk on highly waxed floors.

• The nurse is reviewing the medical record for a client who has been diagnosed with Hodgkin's

disease. The nurse should check which diagnostic test noted in the client's record to determine the stage of the disease?

Correct answer: Positron emission topography (PET) scan

Chronic progressive neoplastic disorder of lymphoid tissue. Characterized by painless enlargement of lymph nodes with progression to extralymphatic sites, such as the spleen and liver. PET scan with or without computed tomography is used to diagnose and determine the stage of the disease.

• A client's electrocardiogram (ECG) strip shows atrial and ventricular rates of 70

complexes/minute. The PR interval is 0.16 second, the QRS complex measures 0.06 second, and the PP interval is slightly irregular. How should the nurse report this rhythm?

Correct answer: Sinus dysrhythmia

Sinus dysrhythmia has all of the characteristics of normal sinus rhythm except for the presence of an irregular PP interval. Because of phasic changes in the rate of firing of the sinoatrial node, which may occur with vagal tone and with respiration. Cardiac output is not affected.

• The nurse has a prescription to give 30 mL of an antacid to a client through a feeding tube.

Which is the priority nursing action?

Correct answer: Assess tube placement.

Tube placement is the priority to prevent aspiration and to ensure that medication delivery will be in the stomach.

• The nurse is caring for a client with leukemia who is receiving intravenous chemotherapy.

The nurse reviews the laboratory results and notes that the white blood cell count is 2000 mm 3 (2 × 10 9 /L), the platelet count is 150,000 mm 3

(150 × 10

9 /L), the clotting time is 10 minutes, and the ammonia level is 20 mcg/dL (12 mcmol/L). Which nursing action would be appropriate?

Correct answer: Place the client on neutropenic precautions.

Normal white blood cell count is 5000 to 10,000 mm, when neutropenic precautions need to be implemented when wbc drops, Bleeding precautions need to be initiated when the platelet count

drops below 90,000 to 100,000 mm, The normal platelet count is 150,000 to 400,000 mm, normal clotting time is 8 to 15 minutes, normal ammonia level is 10 to 80 mcg/dL,

• The nurse is evaluating the plan of care for a client with peptic ulcer disease (PUD) who is

experiencing acute pain. The nurse determines that the expected outcomes have been met if the nursing assessment reveals which result?

Correct answer: The client has eliminated any irritating foods from the diet.

Expected outcomes for the client with PUD who is experiencing pain include elimination of irritating foods from the diet, effectiveness of prescribed medications to eliminate pain, self- reporting of absence of pain with medication, and an ability to sleep through the night without pain. The client who continues to be awakened by pain requires further modification of medication therapy, which may include adjustment of timing of histamine H2-receptor antagonist administration or an additional dose of antacid before the time when pain usually awakens the client.

• The nurse is caring for a client after an above-the-knee amputation. The nurse assesses the

residual (remaining) limb and expects to note which finding?

Correct answer: Pink color to the skin flap

Nurse's primary focus is to monitor for signs indicating that there is sufficient tissue perfusion and no hemorrhage. The skin flap at the end of the residual limb should be pink in a light- skinned person.

• The nurse is providing teaching to a transgender female to male client who will be started on

testosterone therapy. Which information should the nurse include in the teaching session? Select all that apply.

Correct answer:

Expect the clitoris to enlarge.Papanicolaou tests are no longer necessary.Liver enzymes and cholesterol levels will need to be monitored.Transitioning from female to male will be started on testosterone therapy to enhance masculinization. Changes are going to take place like physiological changes include deepening of the voice, clitoral growth, breast atrophy, increased libido, laryngeal prominence, weight gain, acne, and headaches. The patient period will stop at the first dose but then return after months so progesterone may be needed to stop menses.

• The nurse is developing a teaching plan for a group of adolescents regarding the causes of

acne. The nurse develops the plan based on which characteristics associated with acne? Select all that apply.

Correct answer:

The exact cause of acne is unknown Acne requires active treatment for control until it resolves Oily skin and a genetic predisposition may be contributing factors for acne