Saunders NCLEX NEWEST AND
LATEST EXAM VERSION With
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The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this method, which
questions would the nurse ask the client? - correct ans:The PQRSTU method is one method of assessing
,pain. With this method, the nurse asks about the following: Precipitating factors (option 6); Quality of
the pain (option 3); Region or Radiation of the pain (option 1); Severity of the pain; Timing of the pain
(continuous or intermittent); and How the pain affects you (option 4). Options 2 and 5 may be questions
that would be asked; however, these are not a part of the PQRSTU method.
The nurse is preparing to administer furosemide (Lasix) to a client with a diagnosis of heart failure.
Which is the most important laboratory test result for the nurse to check before administering this
medication?
1-Blood urea nitrogen
2-Cholesterol level
3-Potassium level
4-Creatinine level - correct ans:Furosemide is a loop diuretic. The medication causes a decrease in the
client's electrolytes, especially potassium, sodium, and chloride. Administering furosemide to a client
with low electrolyte levels could precipitate ventricular dysrhythmias. Options 1 and 4 reflect renal
function. The cholesterol level is unrelated to the administration of this medication.
A nurse caring for a client with a diagnosis of gastrointestinal (GI) bleeding reviews the client's
laboratory results and notes a hematocrit level of 30%. Which action should the nurse take?
1-Report the abnormally low level.
2-Report the abnormally high level.
3-Inform the client that the laboratory result is normal.
4-Place the normal report in the client's medical record. - correct ans:1-Report the abnormally low level.
The normal hematocrit level in a male ranges from 42% to 52%, and 35% to 47 % in a female, depending
on age. A hematocrit level of 30% is a low level and would be reported to the health care provider
because it indicates blood loss; therefore options 2, 3, and 4 are incorrect.
A nurse provides dietary instructions to a client who will be taking warfarin sodium (Coumadin). The
nurse should tell the client to avoid which food item?
1-Grapes
,2-Spinach
3-Watermelon
4-Cottage cheese - correct ans:2-Spinach
Warfarin sodium is an anticoagulant. Anticoagulant medications act by antagonizing the action of
vitamin K, which is needed for clotting. When a client is taking an anticoagulant, foods high in vitamin K
often are omitted from the diet. Vitamin K-rich foods include green leafy vegetables, fish, liver, coffee,
and tea.
A client who has been receiving total parenteral nutrition (TPN) by way of a central venous access device
complains of chest pain and dyspnea. The nurse quickly assesses the client's vital signs and notes that
the pulse rate has increased and the blood pressure has dropped. The nurse determines that the client
is most likely experiencing which problem?
1-Sepsis
2-Air embolism
3-Fluid overload
4-Fluid imbalance - correct ans:2-Air embolism
The signs and symptoms of air embolism include chest pain, dyspnea, hypoxia, anxiety, tachycardia, and
hypotension. The nurse also may hear a loud churning sound over the pericardium on auscultation of
the client's chest. The signs and symptoms of sepsis include fever, chills, and general malaise. Fluid
overload causes increased intravascular volume, which increases the blood pressure and the pulse rate
as the heart tries to pump the extra fluid volume. Fluid overload also causes neck vein distention and
shifting of fluid into the alveoli, resulting in lung crackles. The signs and symptoms of a fluid imbalance
depend on the type of imbalance the client is experiencing.
A client who is receiving intravenous (IV) fluid therapy complains of burning and a feeling of tightness at
the IV insertion site. On assessment, the nurse detects coolness and swelling at the site and notes that
the IV rate has slowed. The nurse determines that which complication has occurred? - correct ans:1-
Infection
2-Phlebitis
3-Infiltration
4-Thrombosis
, An infiltrated IV line is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor,
coolness, and swelling at the IV site result when IV fluid is deposited in the subcutaneous tissue. When
the pressure in the tissues exceeds the pressure in the tubing, the flow of IV solution will slow down or
stop. The corrective action is to remove the catheter and start a new IV line at another site. The
conditions identified in options 1, 2, and 4 are likely to be accompanied by warmth at the site, not
coolness.
A nurse provides instructions to a preoperative client about the use of an incentive spirometer. The
nurse determines that the client needs further instruction if the client indicates that he or she will take
which action?
1-Sit upright when using the device.
2-Inhale slowly, maintaining a constant flow.
3-Place the lips completely over the mouthpiece.
4-After maximal inspiration, hold the breath for 10 seconds and then exhale. - correct ans:4-After
maximal inspiration, hold the breath for 10 seconds and then exhale.
For optimal lung expansion with the incentive spirometer, the client should assume a semi-Fowler's or
high Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales
slowly, with a constant flow through the unit. When maximal inspiration is reached, the client should
hold the breath for 2 or 3 seconds and then exhale slowly
The nurse is monitoring a client who has a closed chest tube drainage system. The nurse notes
fluctuation of the fluid level in the water-seal chamber during inspiration and expiration. On the basis of
this finding, the nurse should make which interpretation?
1-There is a leak in the system.
2-The chest tube is functioning as expected.
3-The amount of suction needs to be decreased.
4-The occlusive dressing at the insertion site needs reinforcement. - correct ans:2-The chest tube is
functioning as expected.
LATEST EXAM VERSION With
Expected real and comprehensive
Questions and Revised Correct
Answers Guarantee Pass A+
Professional Academic Assistance Services
Services Offered
Proctored Exam Assistance
Online Class Management (Full Course Support)
Exam Preparation & Study Materials
Assignments and Coursework Support
Essays and Research Papers
Discussion Posts and Replies
The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this method, which
questions would the nurse ask the client? - correct ans:The PQRSTU method is one method of assessing
,pain. With this method, the nurse asks about the following: Precipitating factors (option 6); Quality of
the pain (option 3); Region or Radiation of the pain (option 1); Severity of the pain; Timing of the pain
(continuous or intermittent); and How the pain affects you (option 4). Options 2 and 5 may be questions
that would be asked; however, these are not a part of the PQRSTU method.
The nurse is preparing to administer furosemide (Lasix) to a client with a diagnosis of heart failure.
Which is the most important laboratory test result for the nurse to check before administering this
medication?
1-Blood urea nitrogen
2-Cholesterol level
3-Potassium level
4-Creatinine level - correct ans:Furosemide is a loop diuretic. The medication causes a decrease in the
client's electrolytes, especially potassium, sodium, and chloride. Administering furosemide to a client
with low electrolyte levels could precipitate ventricular dysrhythmias. Options 1 and 4 reflect renal
function. The cholesterol level is unrelated to the administration of this medication.
A nurse caring for a client with a diagnosis of gastrointestinal (GI) bleeding reviews the client's
laboratory results and notes a hematocrit level of 30%. Which action should the nurse take?
1-Report the abnormally low level.
2-Report the abnormally high level.
3-Inform the client that the laboratory result is normal.
4-Place the normal report in the client's medical record. - correct ans:1-Report the abnormally low level.
The normal hematocrit level in a male ranges from 42% to 52%, and 35% to 47 % in a female, depending
on age. A hematocrit level of 30% is a low level and would be reported to the health care provider
because it indicates blood loss; therefore options 2, 3, and 4 are incorrect.
A nurse provides dietary instructions to a client who will be taking warfarin sodium (Coumadin). The
nurse should tell the client to avoid which food item?
1-Grapes
,2-Spinach
3-Watermelon
4-Cottage cheese - correct ans:2-Spinach
Warfarin sodium is an anticoagulant. Anticoagulant medications act by antagonizing the action of
vitamin K, which is needed for clotting. When a client is taking an anticoagulant, foods high in vitamin K
often are omitted from the diet. Vitamin K-rich foods include green leafy vegetables, fish, liver, coffee,
and tea.
A client who has been receiving total parenteral nutrition (TPN) by way of a central venous access device
complains of chest pain and dyspnea. The nurse quickly assesses the client's vital signs and notes that
the pulse rate has increased and the blood pressure has dropped. The nurse determines that the client
is most likely experiencing which problem?
1-Sepsis
2-Air embolism
3-Fluid overload
4-Fluid imbalance - correct ans:2-Air embolism
The signs and symptoms of air embolism include chest pain, dyspnea, hypoxia, anxiety, tachycardia, and
hypotension. The nurse also may hear a loud churning sound over the pericardium on auscultation of
the client's chest. The signs and symptoms of sepsis include fever, chills, and general malaise. Fluid
overload causes increased intravascular volume, which increases the blood pressure and the pulse rate
as the heart tries to pump the extra fluid volume. Fluid overload also causes neck vein distention and
shifting of fluid into the alveoli, resulting in lung crackles. The signs and symptoms of a fluid imbalance
depend on the type of imbalance the client is experiencing.
A client who is receiving intravenous (IV) fluid therapy complains of burning and a feeling of tightness at
the IV insertion site. On assessment, the nurse detects coolness and swelling at the site and notes that
the IV rate has slowed. The nurse determines that which complication has occurred? - correct ans:1-
Infection
2-Phlebitis
3-Infiltration
4-Thrombosis
, An infiltrated IV line is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor,
coolness, and swelling at the IV site result when IV fluid is deposited in the subcutaneous tissue. When
the pressure in the tissues exceeds the pressure in the tubing, the flow of IV solution will slow down or
stop. The corrective action is to remove the catheter and start a new IV line at another site. The
conditions identified in options 1, 2, and 4 are likely to be accompanied by warmth at the site, not
coolness.
A nurse provides instructions to a preoperative client about the use of an incentive spirometer. The
nurse determines that the client needs further instruction if the client indicates that he or she will take
which action?
1-Sit upright when using the device.
2-Inhale slowly, maintaining a constant flow.
3-Place the lips completely over the mouthpiece.
4-After maximal inspiration, hold the breath for 10 seconds and then exhale. - correct ans:4-After
maximal inspiration, hold the breath for 10 seconds and then exhale.
For optimal lung expansion with the incentive spirometer, the client should assume a semi-Fowler's or
high Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales
slowly, with a constant flow through the unit. When maximal inspiration is reached, the client should
hold the breath for 2 or 3 seconds and then exhale slowly
The nurse is monitoring a client who has a closed chest tube drainage system. The nurse notes
fluctuation of the fluid level in the water-seal chamber during inspiration and expiration. On the basis of
this finding, the nurse should make which interpretation?
1-There is a leak in the system.
2-The chest tube is functioning as expected.
3-The amount of suction needs to be decreased.
4-The occlusive dressing at the insertion site needs reinforcement. - correct ans:2-The chest tube is
functioning as expected.
