Saunders Comprehensive NCLEX Review Questions (5th Ed.) 66 questions with complete solution graded A+

S. A nurse notes blanching, coolness, and edema at the peripheral intravenous (IV) site. Based on these findings, the nurse implements which action? a. Discontinues the IV b. Applies a warm compress c. Checks for a blood return d. Measures the area of infiltration - a (This question requires that you focus on the data identified 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 most appropriate action is to discontinue the IV to prevent any further damage.) S. A nurse has received the client assignment for the day. Which client should the nurse assess first? a. The client who has a nasogastric tube attached to intermittent suction b. The client who needs to receive subcutaneous insulin before breakfast c. The client who is 2 days postoperative and is complaining of incisional pain d. The client who has a blood glucose level of 50 mg/dL and complaints of blurred vision - d(This question requires you to establish priorities by comparing the needs of each client and deciding which need is urgent. The client described in option 4 has a 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, they are not a priority and can wait until the client in option 4 is stabilized.) S. A nurse prepares to care for a client on contact precautions who has a hospital-acquired infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator, which requires frequent suctioning. The nurse assembles which of the following necessary protective items before entering the client's room? a. Gloves and a gown b. Gloves, mask, and goggles c. Gloves, mask, gown, and goggles d. Gloves, gown, and shoe protectors - c