NCLEX-RN review by Saunders 6th ed. Questions With Correct Answers 2023 A+

NCLEX-RN review by Saunders 6th ed. Questions With Correct Answers 2023 A+ A health care provider prescribes 1 unit of packed red blood cells to be infused over 4 hours. The unit of blood contains 250 mL. The drop factor is 15 drops (gtt)/1 mL. The nurse should set the flow rate at how many drops per minute? Fill in the blank. Round the answer to the nearest whole number. - Correct Answer: 16 gtt/min Rationale: Use the following formula to calculate the infusion rate. Total volume × Drop factor -------------------------- = gtt/min Time in minutes 250 mL × 15 gtt 3750 ---------------------------- = ---- 240 minutes (60 min × 4 hrs) 240 = 15.625, or 16 gtt/min A health care provider prescribes 3000 mL of D5W to infuse over a 24-hour period. The drop factor is 10 drops (gtts)/mL. The nurse sets the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number. - Correct Answer: 21 gtt/min Rationale: Use the intravenous (IV) flow rate formula. Total volume × Drop factor -------------------------- = gtt/min Time in minutes 3000 mL × 10 gtt 30000 ---------------- = ----- 1440 minutes 1440 = 20.8 or 21 gtt/min An adult client has had serum electrolyte levels drawn. The nurse receiving the results by telephone from the laboratory should be most concerned with which finding? - Potassium level, 5.4 mEq/L Rationale: The normal adult ranges of serum electrolyte levels are sodium, 135 to 145 mEq/L; chloride, 98 to 107 mEq/L; potassium, 3.5 to 5.0 mEq/L; and bicarbonate (venous), 22 to 29 mEq/L. The only abnormal value identified above is the serum potassium level, which would be the one of most concern to the nurse because of potential cardiac dysrhythmias. The nurse is assessing the intravenous (IV) dressing of a client with a peripheral IV infusion running. The date on the dressing is 7/25 (July 25). The nurse documents on the client's record that the dressing should be changed on which date? - 7/28 Rationale: IV site dressings should be changed every 48 to 72 hours, which is every 2 to 3 days. With an insertion date of 7/25, the due date for change, depending on agency policy, would be 7/27 or 7/28. It would be unnecessary, uncomfortable, and not cost effective to change the site dressing daily (option 1). Changing the site dressing every 5 or 7 days (options 3 and 4) would place the client at greater risk for infection or other catheter complications. Before enema administration, which position should the nurse assists the client to assume? - Left lateral position, with the right leg acutely flexed Rationale: The sigmoid and descending colons are located on the left side. Therefore the left lateral position uses gravity to facilitate the flow of solution into the sigmoid and descending colons. Acute flexion of the right leg allows for adequate exposure of the anus. The remaining options are incorrect positions. A hospitalized client who has been placed on contact precautions has been prescribed to have a chest radiograph in the radiology department. The nurse should plan to take which action on receipt of this prescription? - Question the health care provider about whether a portable chest radiograph may be obtained. The client who is placed on contact precautions has a high microorganism count in some type of body secretion (such as feces or wound drainage). This client is placed in a private room whenever possible and is removed from the room only when absolutely necessary. Client transport should be done only for essential purposes. Notification of departmental personnel and disinfection of any environmental surfaces with which the client has contact are imperative. The nurse is reviewing the laboratory test results for a client seen in the clinic. The nurse determines that the white blood cell (WBC) count is normal if which value is noted on the laboratory report? - 8600 cells/mm3 Rationale: The normal WBC count ranges from 4500 to 11,000 cells/mm3. Options 1 and 2 indicate low values. Option 4 indicates an elevated value. A client is at risk for pulmonary embolism and is on anticoagulant therapy with warfarin sodium (Coumadin). The client's prothrombin time is 20 seconds, with a control of 11 seconds. How should the nurse interpret these results? - Client results are within the therapeutic range. Rationale: The therapeutic range for prothrombin time is 1.5 to 2 times the control for clients at high risk for thrombus. Based on the client's control value, the therapeutic range for this individual would be 16.5 to 22 seconds; therefore the result is within the therapeutic range. The nurse is caring for a client with meningococcal pneumonia and implements which transmission-based precautions for this client? - Private room or cohort client Rationale: Meningococcal pneumonia is transmitted by droplet infection. Precautions for this disease include a private room or cohort client and use of a standard precaution mask. Private negative airflow pressure rooms and personal respiratory protection devices are required for clients with airborne disease such as tuberculosis. When appropriate, a mask must be worn by the client and not the staff when the client leaves the room. A client has been receiving a series of medications as part of intravenous antineoplastic therapy. The nurse should implement neutropenic precautions after noting which laboratory result for this client? - White blood cell (WBC) count of 2000 cells/mm3 Rationale: The normal WBC is 5000 to 10,000 cells/mm3. When the WBC count drops, neutropenic precautions should be implemented to protect the client from infection. Bleeding precautions should be initiated when the platelet count drops; bleeding precautions include avoiding trauma such as from rectal temperatures or injections. The normal platelet count is 150,000 to 450,000 cells/mm3. The normal clotting time is 8 to 15 minutes. The normal ammonia value is 10 to 80 mcg/dL. An adolescent is admitted to the hospital after an accidental gunshot wound to the foot. The nurse should plan to take which action as a first step for the prevention of future injury? - Explore the client's knowledge of gun safety. Rationale: A leading cause of accidental death in the adolescent population is improper use of firearms. Before implementing firearm safety goals, the nurse needs to obtain baseline data through a firearm safety history, which is described in the correct option. Option 2 may be indicated because of the relationships among accidents, impulsivity, and risktaking behaviors, but assessing past risk-taking behaviors would not be the first step directed at prevention. Option 3 may be effective, but referral to a firearm safety course would not come before assessing the client's knowledge of gun safety. Option 4 may or may not be effective, at some point, for this client. When caring for a client with an internal radiation implant, the nurse should observe which principles? Select all that apply. - Keeping pregnant women out of the client's room. Placing the client in a private room with a private bath. Wearing a lead shield when providing direct client care. Rationale: The time that the nurse spends in a room of a client with an internal radiation implant is 30 minutes per 8-hour shift. The client must be placed in a private room with a private bath. The nurse should wear a lead shield to reduce the transmission of radiation. The dosimeter film badge must be worn when in the client's room. Children younger than 16 years of age and pregnant women are not allowed in the client's room. The clinic nurse notes that, after several eye examinations, the health care provider has documented a diagnosis of legal blindness in a client's chart. The nurse reviews the results of the Snellen chart test, expecting to note which finding? - 20/200 vision Rationale: Legal blindness is defined as 20/200 or less with corrected vision (glasses or contact lenses) or visual acuity of less than 20 degrees of the visual field in the better eye. Therefore options 1, 2, and 3 are incorrect. The nurse caring for an Orthodox Jewish client plans a diet that adheres to the practices of the client's faith. The nurse recognizes that which principles are consistent with dietary kosher laws? - Continues...