NURSING 221: NCLEX SAUNDERS REVIEW |CCTC

NURSING 221: NCLEX REVIEW The nurse is preparing for suctioning an unconscious client who has a tracheostomy. The nurse should perform which actions for this procedure? Select all that apply 1) Suction equipment should be kept at the bedside of an unconscious client, regardless of whether an artificial airway is used. The nurse auscultates breath sounds every 2 to 4 hours, or more frequently, to determine if suctioning is needed. The client should be hyperoxygenated before, during, and after suctioning to minimize cerebral hypoxia. Intermittent suction should be applied while the catheter is being withdrawn, not while it is being inserted. Suctioning should not be performed for longer than 10 seconds at one time to prevent cerebral hypoxia and a rise in intracranial pressure. Keeping a supply of suction catheters at the bedside 2. Auscultating breath sounds to determine the need for suctioning 3. Hyperoxygenating the client before, during, and after suctionin 3)The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. The cervix is dilated completely. The spontaneous urge to push is initiated from perineal pressure. Rationale: The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. The woman has a strong urge to push in stage 2 from perineal pressure. 4) A client diagnosed with depression and prescribed tranylcypromine sulfate has been instructed on the appropriate diet. The nurse determines that the client understands the diet if which foods are selected from the dietary menu? Fried haddock, baked potato, and a cola drink Rationale: Tranylcypromine sulfate is a monoamine oxidase inhibitor (MAOI) that is used to treat depression. A tyramine-restricted diet is required while on this medication to avoid hypertensive crisis, a life-threatening effect of the medication. Foods to be avoided are meats prepared with tenderizer, smoked or pickled fish, beef or chicken liver, and dry sausage (salami, pepperoni, bologna). In addition, figs; bananas; aged cheese; yogurt and sour cream beer, red wine, and other alcoholic beverages; soy sauce; yeastextract; chocolate; caffeine; and aged, pickled, fermented, or smoked foods need to be avoided. 5) A client with schizophrenia has been started on medication therapy with clozapine. The nurse should assess the results of which laboratory study to monitor for adverse effects from this medication? White blood cell count Rationale: A client taking clozapine may experience agranulocytosis, which is monitored by reviewing the results of the white blood cell count. Treatment is interrupted if the white blood cell count decreases to less than 3000 mm3 (3 × 109/L). Agranulocytosis could be fatal if undetected and untreated. The other laboratory studies are not related specifically to the use of this medication. 6) A home care nurse has observed a client self-administer a dose of an adrenergic bronchodilator via metered-dose inhaler. Within a short time, the client begins to wheeze loudly. The nurse understands that this is the result of which occurrence? Paradoxical bronchospasm, which must be reported to the health care provider (HCP) Rationale: The client taking adrenergic bronchodilators may experience paradoxical bronchospasm, which is evidenced by the client's wheezing. This can occur with excessive use of inhalers. Further medication should be withheld and the HCP should be notified. The remaining options are incorrect interpretations. A client taking verapamil has been given information about side effects of this medication. The nurse determines that the client understands the information if the client states to watch for which most common side effect of this medication? Rationale Verapamil is a calcium channel blocker. The most common complaint with the use of verapamil is constipation. Other frequent side effects are dizziness, facial flushing, headache, and edema of the hands and feet. Weight loss, nasal stuffiness, and abdominal cramping are not associated with the use of this medication 7) A client taking verapamil has been given information about side effects of this medication. The nurse determines that the client understands the information if the client states to watch for which most common side effect of this medication? Constipation Rat: Verapamil is a calcium channel blocker. The most common complaint with the use of verapamil is constipation. ......