Saunders NCLEX Practice- Questions and answers correct and verified 100%

Saunders NCLEX Practice- Questions and answers correct and verified 100%Saunders NCLEX Practice- Questions and answers correct and verified 100% The nurse notes blanching, coolness, and edema at the peripheral 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 blood return through the line 4. measure the area of infiltration - correct answer-1. remove the IV - prevent any further damage that may be caused by infiltration The nurse has received the client assignments for the day. Which client should the nurse see first? 1. the client who needs SC insulin before breakfast 2. the client who has a NG tube set on intermittent suction 3. the client who is 2 days post-op and is complaining of pain at the incision site 4. the client with a blood glucose of 50 mg/dl and is complaining of blurred vision - correct answer-4. the client with a blood glucose of 50 mg/dl and is complaining of blurred vision- hypoglycemia can be life threatening, so intervene and treat this first! The nurse prepares to care for a client on contact precautions admitted with MRSA. The client has an abdominal wound that requires irrigation and has a tracheostomy that is hooked up to a mechanical ventilator, which requires frequent suctioning. The nurse should don which protective equipment before entering the patient's room? 1. gloves and gown 2. gloves and face shield 3. gloves, gown, and face shield 4. gloves, gown, shoe protectors - correct answer-3. gloves, gown, and face shield The nurse is choosing age-appropriate toys for a toddler. Which toy selection is the best choice for this age? 1. puzzle 2. toy soldiers 3. large stacking-blocks 4. card game with large pictures - correct answer-3. large stacking-blocks- identify safety risks when interacting with smaller children- choking hazards, inability to comprehend rules, etc. A client diagnosed with coronary artery disease has selected guided imagery to help cope with the psychological stress caused from the diagnosis. Which statement made by the client indicates an understanding of this stress reduction measure? 1. "This will help only if I play music at the same time." 2. "This will work for me only if I am alone and in a quiet area." 3. "I need to do this only when I lie down in case I fall asleep." 4. "The best thing about this is that I can use it anywhere at anytime." - correct answer-4. "The best thing about this is that I can use it anywhere at anytime." - guided imagery involves the client creating an image in the mind, concentrating on that image, and gradually becoming less aware of surrounding stimuli. A client with Parkinson's disease develops akinesia (freezing or no movement) while ambulating, increasing the risk for falls. Which suggestion by the nurse would cause the client to alleviate this problem? 1. use a wheelchair when moving around 2. stand erect and use a cane while ambulating 3. keep feet close together when walking and use a walker 4. consciously think about walking over imaginary lines on the floor - correct answer-4. consciously think about walking over imaginary lines on the floor- clients with Parkinson's develop bradykinesia (moving slowly) or akinesia. Having these clients imagine lines on the floor to walk over can keep them moving forward while remaining safe. The nurse monitors a client receiving digoxin for which early manifestation of digoxin toxicity? 1. anorexia 2. facial pain 3. photophobia 4. jaundice - correct answer-1. anorexia- digoxin is a cardiac glycoside used to manage/treat heart failure and A-fib. The most common early manifestations of toxicity include GI disturbances- nausea, vomiting, anorexia. A MRI is ordered for a patient with a suspected brain tumor. The nurse should implement which action to prepare the patient for this test? 1. shave the groin for insertion of a femoral catheter 2. remove all metal-containing objects from the client 3. keep the client NPO before procedure 4. instruct the client of inhalation techniques for the administration of the radioisotope. - correct answer-2. remove all metal-containing objects from the client A client with renal insufficiency has a Mg+ level of 3.5 mEq/L. On the basis of this laboratory result, the nurse expects which client symptom? 1. hyperpnea 2. drowsiness 3. hypertension 4. physical hyperactivity - correct answer-2. drowsiness- normal Mg+ level is 1.5-2.5 mEq/L. This client's level indicates hypermagnesemia- leads to neurological manifestations such as neurological depression- drowsiness, sedation, lethargy, muscle weakness, respiratory depression A client is scheduled for an angioplasty. The client states, "I am so afraid that this procedure will hurt and will make me worse off than I already am." Which response by the nurse is appropriate? 1. "Can you tell me what you understand about this procedure?" 2. "Your fears are a sign that you really should have this procedure performed." 3. "These are normal fears, but please be assured that everything will be okay." 4. "Try not to worry. This is a well-known and easy procedure for the health care provider to perform." - correct answer-1. "Can you tell me what you understand about this procedure?" - therapeutic communication! Explore the client's feelings and concerns, determine their understanding of the procedure. The ED nurse is caring for a child suspected of acute epiglottitis. Which interventions apply in the care of the child? SATA. 1. obtain a throat culture 2. ensure a patent airway 3. prepare the child for a chest x-ray 4. maintain child in supine position 5. obtain a pediatric-size tracheostomy tray 6. place the child on an O2 monitor - correct answer-2. ensure a patent airway 3. prepare the child for a chest x-ray 5. obtain a pediatric-size tracheostomy tray 6. place the child on an O2 monitor acute epiglottitis- serious obstructive inflammatory process that requires immediate intervention- interventions pertaining to AIRWAY IS PRIORITY A client who experienced a MI is being monitored via cardiac telemetry. The nurse notes the sudden onset of this cardiac rhythm on the monitor and immediately takes which action? 1. take client's blood pressure 2. initiates CPR 3. places a nitroglycerin tablet under the client's tongue 4. continues to monitor client and contacts healthcare provider - correct answer-2. initiates CPR - CPR is initiated until a defibrillator can be used. The nurse should place the patient in what position before administering an enema? 1. prone position 2. supine position 3. sims position 4. dorsal recumbent position - correct answer-3. sims position - left side-lying position allows enema solution to flow downward by gravity along the natural curve of the sigmoid colon and rectum. The nurse is caring for a client with a diagnosis of heart failure who suddenly complains of shortness of breath and dyspnea. The nurse should take which immediate action? 1. administer O2 to the client 2. prepare to administer furosemide 3. elevate the HOB 4. call the healthcare provider - correct answer-3. elevate the HOB - eliminate the "what ifs" and focus solely on what you can do for that patient right in that moment, without a provider's order. The nurse is caring for a client who just returned from the recovery room after undergoing abdominal surgery. The nurse should monitor for which EARLY sign of hypovolemic shock? 1. sleepiness 2. increased pulse rate 3. increased depth of respirations 4. increased orientation to surroundings - correct answer-2. increased pulse rate- restlessness is one of the earliest signs, followed by cardiovascular changes such as increase HR and decrease BP. Increased depth of respirations does occur with hypovolemic shock, but it is NOT an early sign. The nurse is teaching a client in skeletal leg traction about measures to increase bed mobility. Which item would be most appropriate for the client to use? 1. hospital bed remote 2. fracture bedpan 3. overhead trapeze 4. educational reading materials - correct answer-3. overhead trapeze- useful in assisting the patient with moving up in the bed and/or placing self on bedpan. The nurse provides medication instruction to a patient receiving digoxin. Which statement by the patient indicates understanding of possible adverse effects of this medication? 1. "blurred vision is expected." 2. "if I am nauseated or vomiting, I should stay on an all-liquid diet and take an antacid until resolved." 3. "this medication may cause headache and weakness, but I should not be worried." 4. "if my pulse rate drops below 60 bpm I should notify my healthcare provider and withhold the medication." - correct answer-4. "if my pulse rate drops below 60 bpm I should notify my healthcare provider and withhold the medication." The nurse has reinforced discharge instruct