Saunders NCLEX-PN

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• The nurse reinforces home care instructions to the

parents of a child hospitalized with pertussis. The child is in the convalescent stage and is being prepared for discharge. Which statement by the parents indicates a need for further teaching?

• "We need to encourage adequate fluid intake."
• "Coughing spells may be triggered by dust or smoke."
• "We need to maintain respiratory precautions and a

quiet environment for at least 2 weeks."

• "Good hand-washing techniques need to be instituted

to prevent spreading the disease to others."

741. 3

Rationale: Pertussis is transmitted by direct contact or respiratory droplets from coughing. The communicable period occurs primarily during the catarrhal stage.Respiratory precautions are not required during the convalescent phase. Options 1, 2, and 4 are components of home care instructions.Test-Taking Strategy: Note the strategic words, need for further teaching. These words indicate a negative event query and the need to select the incorrect statement. Options 1 and 4 can be easily eliminated because they are general interventions associated with convalescence. Knowing that coughing spells are associated with pertussis will assist in directing you to the correct option from the remaining options. In addition, a 2-week period of respiratory precautions is not

required. Review: home care instructions for the child with pertussis.

Level of Cognitive Ability: Evaluating

Client Needs: Safe and Effective Care Environment

Integrated Process: Nursing Process/Evaluation

Content Area: Child Health: Infectious and Communicable Diseases

Priority Concepts: Gas Exchange, Infection

Reference(s): Hockenberry, Wilson (2013), pp. 428, 653-654.

• A client enters the emergency department confused,

twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. Upon assessment, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 172 mEq/L. Which interventions would the health care provider likely prescribe? Select all that apply.

• Monitor the vital signs.
• Monitor intake and output.
• Increase water intake orally.
• Monitor the electrolyte levels.
• Provide a sodium-reduced diet.
• Administer sodium replacements.

742. 1, 2, 3, 4, 5

Rationale: Hypernatremia is described as having a serum sodium level that

exceeds 145 mEq/L. Signs and symptoms would include dry mucous membranes, loss of skin turgor, thirst, flushed skin, elevated temperature, oliguria, muscle twitching, fatigue, confusion, and seizures. Interventions include monitoring fluid balance, monitoring vital signs, reducing dietary intake of sodium, monitoring electrolyte levels, and increasing oral intake of water. Sodium replacement therapy would not be prescribed for a client with hypernatremia.

Test-Taking Strategy: Focus on the subject, a sodium level of 172 mEq/L.

Knowledge that this level is elevated and knowledge of the treatment for

hyperkalemia will direct you to the correct options. Review: hypernatremia.

Level of Cognitive Ability: Analyzing

Client Needs: Physiological Integrity

Integrated Process: Nursing Process/Planning

Content Area: Fundamental Skills: Fluids & Electrolytes

Priority Concepts: Clinical Judgment, Fluid and Electrolyte Balance

Reference(s): deWit, Kumagai (2013), pp. 41-42.

• The nurse is monitoring a client receiving glipizide

(Glucotrol). Which outcome indicates an ineffective response from the medication?

• A decrease in polyuria
• A decrease in polyphagia
• A fasting plasma glucose of 100 mg/dL
• A glycosylated hemoglobin level of 12%

743. 4

Rationale: Glipizide (Glucotrol) is an oral hypoglycemic agent administered to

decrease the serum glucose level and the signs and symptoms of hyperglycemia.Therefore, a decrease in both polyuria and polyphagia would indicate a therapeutic response. Laboratory values are also used to monitor a client's response to treatment. A fasting blood glucose level of 100 mg/dL is within normal limits. However, glycosylated hemoglobin of 12% indicates poor glycemic control.

Test-Taking Strategy: Focus on the subject, an ineffective response to the

medication. Recalling that glipizide is an oral hypoglycemic agent tells you to look for an option that would indicate hyperglycemia (lack of response to the medication). Options 1 and 2 are comparable or alike options and are eliminated first. Next, eliminate option 3 because it is a normal blood glucose level. Review: glipizide (Glucotrol).

Level of Cognitive Ability: Evaluating

Client Needs: Physiological Integrity

Integrated Process: Nursing Process/Evaluation

Content Area: Pharmacology: Endocrine Medications

Priority Concepts: Adherence, Glucose Regulation

Reference(s): deWit, Kumagai (2013), pp. 827, 862.

• The nurse is reinforcing discharge instructions to a

client receiving sulfisoxazole. Which should be included in the plan of care for instructions?

• Maintain a high fluid intake.
• Discontinue the medication when feeling better.
• If the urine turns dark brown, call the health care

provider immediately.

• Decrease the dosage when symptoms are improving

to prevent an allergic response.

744. 1

Rationale: Each dose of sulfisoxazole should be administered with a full glass of water, and the client should maintain a high fluid intake. The medication is more soluble in alkaline urine. The client should not be instructed to taper or discontinue the dose. Some forms of sulfisoxazole cause the urine to turn dark brown or red. This does not indicate the need to notify the health care provider.

Test-Taking Strategy: Focus on the subject, instructions for a client taking a

sulfonamide. General principles related to medication administration will assist in eliminating options 2 and 4. Options 2 and 4 are also comparable or alike options.Next, it is necessary to know that the client should maintain a high fluid intake.

Review: sulfisoxazole.

Level of Cognitive Ability: Applying

Client Needs: Physiological Integrity

Integrated Process: Teaching and Learning

Content Area: Pharmacology: Renal and Urinary Medications

Priority Concepts: Client Education, Elimination

Reference(s): deWit, Kumagai (2013), p.

• Before administering an intermittent tube feeding

through a nasogastric tube, the nurse checks for gastric residual volume. Which is the best rationale for checking gastric residual volume before administering the tube feeding?

• Observe the digestion of formula.
• Check fluid and electrolyte status.
• Evaluate absorption of the last feeding.
• Confirm proper nasogastric tube placement.

745. 3

Rationale: All the stomach contents are aspirated and measured before

administering a tube feeding. This procedure measures the gastric residual volume. The gastric residual volume is checked to confirm whether undigested formula from a previous feeding remains and thereby evaluates the absorption of the last feeding. It is important to check the gastric residual before administration of a tube feeding. A full stomach could result in overdistention, thus predisposing the client to regurgitation and possible aspiration. If residual feeding is obtained, the health care provider's prescription and agency policy are checked to determine the course of action (hold or reduce the volume of the intermittent tube feeding).Test-Taking Strategy: Note the strategic word, best. Next, note the subject, the purpose of checking residual volume. Think about the complications associated with tube feedings and the risk of aspiration with an overdistended stomach.

Review: the purpose for checking gastric residual volume.

Level of Cognitive Ability: Applying

Client Needs: Physiological Integrity

Integrated Process: Nursing Process/Data Collection

Content Area: Adult Health: Gastrointestinal

Priority Concepts: Clinical Judgment, Nutrition

Reference(s): Cooper, Gosnell (2015), pp. 676, 680.

• A postoperative client requests medication for

flatulence (gas pains). Which medication from the following PRN list should the nurse administer to this client?

• Ondansetron (Zofran)
• Simethicone (Mylicon)
• Acetaminophen (Tylenol)
• Magnesium hydroxide (milk of magnesia, MOM)

746. 2

Rationale: Simethicone is an antiflatulent used in the relief of pain caused by

excessive gas in the gastrointestinal tract. Ondansetron is used to treat postoperative nausea and vomiting. Acetaminophen is a nonopioid analgesic.Magnesium hydroxide is an antacid and laxative.Test-Taking Strategy: Note the subject, a medication to treat flatulence (gas pains).Recalling the classifications of the medications in the options will direct you to the

correct option. Review: simethicone (Mylicon).

Level of Cognitive Ability: Applying

Client Needs: Physiological Integrity

Integrated Process: Nursing Process/Implementation

Content Area: Pharmacology: Gastrointestinal Medications

Priority Concepts: Clinical Judgment, Pain

Reference(s): Hodgson, Kizior (2015), pp. 1104-1105.

• A client is admitted to the hospital with a diagnosis of

major depression. During the admission interview, the nurse determines that a major concern is the client's altered nutrition related to poor nutritional intake. Which nursing intervention related to altered nutrition should be the initial choice?

• Weigh the client three times per week, before breakfast.
• Explain to the client the importance of a good

nutritional intake.

• Report the nutritional concern to the psychiatrist and

obtain a nutritional consult as soon as possible.

• Offer the client several small, frequent meals daily, and

schedule brief nursing interactions with the client during these times.

747. 4

Rationale: Change in appetite is one of the major symptoms of depression.

Offering the client several small, frequent meals and the nurse's presence at that time to support, encourage, or perhaps even feed the client is the most appropriate intervention. A client with depression experiences poor concentration and will not understand the importance of an adequate nutritional intake. Weighing the client does not address how to increase nutritional intake.Reporting the nutritional problems to the psychiatrist is correct to some degree, but it does not address how one might increase food intake.Test-Taking Strategy: Note the strategic word, initial, and focus on the subject, the poor nutritional intake. The correct option is the only option that addresses the altered nutrition concretely and designs a method in which the client will feasibly

increase the nutritional intake. Review: nutritional concerns with depression.

Level of Cognitive Ability: Applying

Client Needs: Physiological Integrity

Integrated Process: Nursing Process/Implementation

Content Area: Mental Health

Priority Concepts: Mood and Affect, Nutrition

Reference(s): deWit, Kumagai (2013), p. 1058.

• A client received 20 units of NPH insulin

subcutaneously at 8:00 am. The nurse should check the

client for a potential hypoglycemic reaction at which time?

1. 5:00 pm

2. 10:00 am

3. 11:00 am

4. 11:00 pm

748. 1

Rationale: NPH is intermediate-acting insulin. Its onset of action is 1 to 2½ hours, it peaks in 4 to 12 hours, and its duration of action is 24 hours. Hypoglycemic reactions most likely occur during peak time.Test-Taking Strategy: Focus on the subject, NPH insulin. Recalling that peak action

is between 4 and 12 hours will direct you to the correct option. Review: the

characteristics of NPH insulin.

Level of Cognitive Ability: Applying

Client Needs: Physiological Integrity

Integrated Process: Nursing Process/Implementation

Content Area: Pharmacology: Endocrine Medications974

Priority Concepts: Clinical Judgment, Glucose Regulation

Reference(s): Lehne (2013), p. 712.

• The nurse assists in developing a plan of care for a

client with hyperparathyroidism receiving calcitonin- human (Cibacalcin). Which outcome has the highest priority regarding this medication?

• Relief of pain
• Absence of side effects
• Reaching normal serum calcium levels
• Verbalization of appropriate medication knowledge
• The nursing instructor asks a nursing student about

the cause of hemophilia. The student correctly responds by telling the instructor which fact about hemophilia?

• Hemophilia is a Y-linked hereditary disorder.
• A splenectomy resolves the bleeding disorders.
• Hemophilia A results from deficiency of factor VIII.
• A bone marrow transplant is the treatment of choice.