SAUNDERSCOMPREHENSIVE

FROM4143TO5142

SAUNDERSCOMPREHENSIVE

REVIEWFORNCLEXFOUR-TEST

BANKLATESTGUIDE

1)Achildwithanautismspectrumdisorder(ASD)isbeing admittedtothehospitalfordiagnostictests.Whichroom assignmentisthemostappropriateforthechild?✓ Privateroom 2)Thelaboranddeliveryroomnursehasjustreceivedreports on4clients.Afterreviewingtheclientdata,thenurse shouldassesswhichclientfirst? 1 / 4

FROM4143TO5142

✓ Aclientwhohasjustreceivedanintravenous loadingdoseofmagnesiumsulfatetostoppreterm labor 3)Thenursehasdevelopedateachingplanforaclientwith hypertensionregardingtheadministrationofprescribed medications.Whatistheinitialnursingaction?✓ Assesstheclient'sreadinesstolearn.4)Aclientwithcancerisreceivingintravenousmorphine sulfateforpain.Whenwritingtheplanofcareforthis client,thenurseshouldincludewhichactionasthe priorityaction?✓ Monitorrespiratorystatus.5)Thenurseispreparingtosuctiontheairwayofaclientwho hasatracheostomytubeandgathersthesuppliesneededfor theprocedure.Inorderofpriority,whichactionsshould thenursetaketoperformthisprocedure?Arrangethe actionsintheorderthattheyshouldbeperformed.All optionsmustbeused.✓ 1)PlacetheclientinasemiFowler's position.✓ 2)Turnonthesuctiondeviceandsetthe regulatorat80mmHg.✓ 3)Attachthesuctiontubingtothesuction catheter.✓ 4)Hyperoxygenatetheclient.✓ 5)Insertthecatheterintothetracheostomy untilresistanceismet,andthenpullitback1 cm. 2 / 4

FROM4143TO5142

✓ 6)Applyintermittentsuctionandslowly withdrawthecatheterwhilerotatingitbackand forth.6)Thenursenotesblanching,coolness,andedemaataclient's peripheralintravenous(IV)site.Whichnursingactionis thepriority?✓ RemovetheIVcatheter.7)Aclienthasaprescriptiontobeginaninfusionof1000mL of5%dextroseinlactatedRinger'ssolution.Theclienthas anintravenous(IV)cannulainserted,andthenurseprepares thesolutionandIVtubing.Arrangetheactionsintheorder thattheyshouldbeperformed.Alloptionsmustbeused.✓ 1)ClosetherollerclampontheIVtubing.✓ 2)SpiketheIVbagandhalf-fillthedrip chamber.✓ 3)Opentherollerclampandfillthetubing.✓ 4)Uncapthedistalendofthetubing.✓ 5)Attachthedistalendofthetubingtothe client.8)Thenurseiscaringfor4pediatricclients.Afterreceiving reportsfromthenightshift,whichchildshouldthenurse assessfirst?✓ A6-week-oldinfantadmittedtothehospital fordecreasedlevelofconsciousness;shakenbaby syndromeissuspected 9)Thenurseisassignedto4clientsonapostoperative surgicalunitataruralhospital.Whenprioritizingthe care,thenurserecognizesthatthehighestpriorityis focusedonwhichclient?✓ Theclientwithproblemsclearingtheairway relatedtoabdominalincisionpain 10) Theemergencydepartmentnurseiscaringforachild withsuspectedepiglottitisandhasensuredthatthechild hasapatentairway.Whichactionisthenextpriorityin thecareofthischild?✓ Preparethechildforachestradiograph. 3 / 4

FROM4143TO5142

11) Thenursinginstructorasksthenursingstudentto identifytheprioritiesofcareforanassignedclient.The nursinginstructordeterminesthatthenursingstudent understandstheclient'sneedswhenwhichstatementismade?✓ "Actualorlife-threateningconcernsarethe priority." 12) Ahospitalizedclientwithtype1diabetesmellitus receivedHumulinNandHumulinRinsulin2hoursago(at

7:30a.m.).Theclientcallsthenurseandreportsthathe

isfeelinghungry,shaky,andweak.Theclientatebreakfast at8a.m.andisduetoeatlunchatnoon.Arrangethe actionsthatthenursewilltakeintheorderthatthey shouldbeperformed.Alloptionsmustbeused.✓ 1)Checktheclient'sbloodglucoselevel.✓ 2)Givetheclient½cup(118mL)offruit juicetodrink.✓ 3)Taketheclient'svitalsigns.✓ 4)Retestthebloodglucoselevel.✓ 5)Givetheclientasmallsnackof carbohydrateandprotein.✓ 6)Documenttheclient'scomplaints,actions taken,andoutcome.13) Anemergencydepartmentnurseispreparingtoreceive4 clientsasaresultofamotorvehiclecrash.Whichvictim shouldthenurseattendtofirst?✓ A45-year-oldmanwithchestpain,shortness ofbreath,anddiaphoresis 14) Thenurseisassignedtocarefor4clients.Which clientshouldthenurseassessfirst?✓ Aclientwhohasaperipheral(indexfinger) oxygensaturationpercentageof85% 15) Thenursehasreceivedherclientassignmentforthe day.Whichclientshouldthenursecareforfirst?✓ Aclientwithpostoperativepainreportedat 7outof10,with10beingtheworst

• / 4