Saunders Comprehensive Review for
the NCLEX-RN Exam Questions &
Answers (Grade A+)
The nurse notes blanching, coolness, and edema at the peripheral
intravenous (IV) site. On the basis of these findings, the nurse
should implement which action?
1. Remove the IV.
2. Apply a warm compress.
3. Check for a blood return.
4. Measure the area of infiltration. -
correct answer ✅Answer: 1
This question requires that you focus on the data 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
appropriate action is to remove the IV to prevent any further
damage. Once the IV is removed, further action should be taken
depending on the medication infusing at the time of infiltration
based on agency protocol but may include aspiration of the fluid
from the site, injection of an antidote, application of warm or cool
compresses for specified time intervals, and elevation of the
extremity.
, Saunders Comprehensive Review for
the NCLEX-RN Exam Questions &
Answers (Grade A+)
The nurse has received the client assignment for the day. Which
client should the nurse assess first?
1. The client who needs to receive subcutaneous insulin before
breakfast
2. The client who has a nasogastric tube attached to intermittent
suction
3. The client who is 2 days postoperative and is complaining of
incisional pain
4. The client who has a blood glucose level of 50 mg/dL (2.8
mmol/L) and complaints of blurred vision -
correct answer ✅Answer: 4
This question addresses the subcategory Management of Care in
the Client Needs category Safe and Effective Care Environment.
Note the strategic word, first, so you
need to establish priorities by comparing the needs of each client
and deciding which need is urgent. The client described in the
correct option has a low 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, their assessments can wait until the
client in the correct option is stabilized.
the NCLEX-RN Exam Questions &
Answers (Grade A+)
The nurse notes blanching, coolness, and edema at the peripheral
intravenous (IV) site. On the basis of these findings, the nurse
should implement which action?
1. Remove the IV.
2. Apply a warm compress.
3. Check for a blood return.
4. Measure the area of infiltration. -
correct answer ✅Answer: 1
This question requires that you focus on the data 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
appropriate action is to remove the IV to prevent any further
damage. Once the IV is removed, further action should be taken
depending on the medication infusing at the time of infiltration
based on agency protocol but may include aspiration of the fluid
from the site, injection of an antidote, application of warm or cool
compresses for specified time intervals, and elevation of the
extremity.
, Saunders Comprehensive Review for
the NCLEX-RN Exam Questions &
Answers (Grade A+)
The nurse has received the client assignment for the day. Which
client should the nurse assess first?
1. The client who needs to receive subcutaneous insulin before
breakfast
2. The client who has a nasogastric tube attached to intermittent
suction
3. The client who is 2 days postoperative and is complaining of
incisional pain
4. The client who has a blood glucose level of 50 mg/dL (2.8
mmol/L) and complaints of blurred vision -
correct answer ✅Answer: 4
This question addresses the subcategory Management of Care in
the Client Needs category Safe and Effective Care Environment.
Note the strategic word, first, so you
need to establish priorities by comparing the needs of each client
and deciding which need is urgent. The client described in the
correct option has a low 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, their assessments can wait until the
client in the correct option is stabilized.
