Saunders NCLEX questions with 100% Verified Solutions | Graded A+
1. The nurse is assessing a The PQRSTU method is one method of as-
client's postoperative pain us- sessing pain. With this method, the nurse
ing the PQRSTU method. Us- asks about the following: Precipitating fac-
ing this method, which ques- tors (option 6); Quality of the pain (option
tions would the nurse ask the 3); Region or Radiation of the pain (option
client? 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; how-
ever, these are not a part of the PQRSTU
method.
2. The nurse is preparing to ad- Furosemide is a loop diuretic. The med-
minister furosemide (Lasix) to ication causes a decrease in the client's
a client with a diagnosis of electrolytes, especially potassium, sodium,
heart failure. Which is the most and chloride. Administering furosemide to a
important laboratory test re- client with low electrolyte levels could pre-
sult for the nurse to check be- cipitate ventricular dysrhythmias. Options 1
fore administering this med- and 4 reflect renal function. The cholesterol
ication? level is unrelated to the administration of this
medication.
1-Blood urea nitrogen
2-Cholesterol level
3-Potassium level
4-Creatinine level
3. A nurse caring for a client 1- Report the abnormally low level.
with a diagnosis of gastroin-
testinal (GI) bleeding reviews The normal hematocrit level in a male
the client's laboratory results ranges from 42% to 52%, and 35% to 47 %
and notes a hematocrit level of in a female, depending on age. A hematocrit
30%. Which action should the level of 30% is a low level and would be re-
nurse take? ported to the health care provider because
it indicates blood loss; therefore options 2,
1- Report the abnormally low 3, and 4 are incorrect.
level.
2- Report the abnormally high
level.
3- Inform the client that the lab-
,Saunders NCLEX questions with 100% Verified Solutions | Graded A+
oratory result is normal.
4- Place the normal report in
the client's medical record.
4. A nurse provides dietary in- 2- Spinach
structions to a client who
will be taking warfarin sodium Warfarin sodium is an anticoagulant. Anti-
(Coumadin). The nurse should coagulant medications act by antagonizing
tell the client to avoid which the action of vitamin K, which is needed for
food item? clotting. When a client is taking an antico-
agulant, foods high in vitamin K often are
1- Grapes omitted from the diet. Vitamin K-rich foods
2-Spinach include green leafy vegetables, fish, liver,
3- Watermelon coffee, and tea.
4- Cottage cheese
5. A client who has been re- 2-Air embolism
ceiving total parenteral nu-
trition (TPN) by way of a The signs and symptoms of air embolism in-
central venous access de- clude chest pain, dyspnea, hypoxia, anxiety,
vice complains of chest pain tachycardia, and hypotension. The nurse
and dyspnea. The nurse quick- also may hear a loud churning sound
ly assesses the client's vital over the pericardium on auscultation of the
signs and notes that the pulse client's chest. The signs and symptoms of
rate has increased and the sepsis include fever, chills, and general
blood pressure has dropped. malaise. Fluid overload causes increased
The nurse determines that the intravascular volume, which increases the
client is most likely experienc- blood pressure and the pulse rate as the
ing which problem? heart tries to pump the extra fluid volume.
Fluid overload also causes neck vein dis-
1- Sepsis tention and shifting of fluid into the alveoli,
2- Air embolism resulting in lung crackles. The signs and
3- Fluid overload symptoms of a fluid imbalance depend on
4- Fluid imbalance the type of imbalance the client is experienc-
ing.
6. A client who is receiving intra- 1- Infection
venous (IV) fluid therapy com- 2-Phlebitis
plains of burning and a feeling 3-Infiltration
,Saunders NCLEX questions with 100% Verified Solutions | Graded A+
of tightness at the IV insertion 4-Thrombosis
site. On assessment, the nurse
detects coolness and swelling An infiltrated IV line is one that has dis-
at the site and notes that the lodged from the vein and is lying in subcuta-
IV rate has slowed. The nurse neous tissue. Pallor, coolness, and swelling
determines that which compli- at the IV site result when IV fluid is deposited
cation has occurred? in the subcutaneous tissue. When the pres-
sure 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 accom-
panied by warmth at the site, not coolness.
7. A nurse provides instructions 4-After maximal inspiration, hold the breath
to a preoperative client about for 10 seconds and then exhale.
the use of an incentive spirom-
eter. The nurse determines For optimal lung expansion with the incen-
that the client needs further in-tive spirometer, the client should assume a
struction if the client indicatessemi-Fowler's or high Fowler's position. The
that he or she will take which mouthpiece should be covered completely
action? and tightly while the client inhales slowly,
with a constant flow through the unit. When
1- Sit upright when using the maximal inspiration is reached, the client
device. should hold the breath for 2 or 3 seconds
2- Inhale slowly, maintaining a and then exhale slowly
constant flow.
3- Place the lips completely
over the mouthpiece.
4- After maximal inspiration,
hold the breath for 10 seconds
and then exhale.
8. The nurse is monitoring a 2- The chest tube is functioning as expected.
client who has a closed chest
tube drainage system. The The presence of fluctuation of the fluid level
nurse notes fluctuation of the in the water-seal chamber indicates a patent
fluid level in the water-seal drainage system. With normal breathing,
, Saunders NCLEX questions with 100% Verified Solutions | Graded A+
chamber during inspiration the water level rises with inspiration and falls
and expiration. On the basis of with expiration. Fluctuation stops if the tube
this finding, the nurse should is obstructed, if the suction is not working
make which interpretation? properly, or if the lung has re-expanded. Op-
tions 1, 3, and 4 are incorrect interpretations
1- There is a leak in the system. of the finding. An air leak may cause ex-
2- The chest tube is function- cessive bubbling in the water seal chamber.
ing as expected. Excessive and vigorous bubbling in the suc-
3- The amount of suction tion control chamber may indicate that the
needs to be decreased. amount of suction needs to be decreased.
4- The occlusive dressing at The status of the dressing is not specifically
the insertion site needs rein- related to the presence of fluctuation of the
forcement. fluid level in the water-seal chamber
9. A nurse is providing morn- 1- Call the health care provider.
ing care to a client who has
a closed chest tube drainage
system to treat a pneumoth- If the chest drainage system is dislodged
orax. When the nurse turns from the insertion site, the nurse immedi-
the client to the side, the ately applies sterile gauze over the site and
chest tube is accidentally calls the health care provider. The nurse
dislodged from the chest. would maintain the client in an upright po-
The nurse immediately applies sition. A new chest tube system may be at-
sterile gauze over the chest tached if the tube requires insertion, but this
tube insertion site. Which is would not be the next action. Pulse oxime-
the nurse's next action? try readings would assist in determining the
client's respiratory status, but the priority ac-
1- Call the health care provider. tion would be to call the health care provider
2- Replace the chest tube sys- in this emergency situation.
tem.
3- Obtain a pulse oximetry
reading.
4- Place the client in a Trende-
lenburg position
10. A nurse reviews the medica- 1- "Do you have any joint pain?"
tion history of a client and
notes that the client is tak- Leflunomide is an immunomodulatory agent
ing leflunomide (Arava). Dur- and has an anti-inflammatory action. The
1. The nurse is assessing a The PQRSTU method is one method of as-
client's postoperative pain us- sessing pain. With this method, the nurse
ing the PQRSTU method. Us- asks about the following: Precipitating fac-
ing this method, which ques- tors (option 6); Quality of the pain (option
tions would the nurse ask the 3); Region or Radiation of the pain (option
client? 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; how-
ever, these are not a part of the PQRSTU
method.
2. The nurse is preparing to ad- Furosemide is a loop diuretic. The med-
minister furosemide (Lasix) to ication causes a decrease in the client's
a client with a diagnosis of electrolytes, especially potassium, sodium,
heart failure. Which is the most and chloride. Administering furosemide to a
important laboratory test re- client with low electrolyte levels could pre-
sult for the nurse to check be- cipitate ventricular dysrhythmias. Options 1
fore administering this med- and 4 reflect renal function. The cholesterol
ication? level is unrelated to the administration of this
medication.
1-Blood urea nitrogen
2-Cholesterol level
3-Potassium level
4-Creatinine level
3. A nurse caring for a client 1- Report the abnormally low level.
with a diagnosis of gastroin-
testinal (GI) bleeding reviews The normal hematocrit level in a male
the client's laboratory results ranges from 42% to 52%, and 35% to 47 %
and notes a hematocrit level of in a female, depending on age. A hematocrit
30%. Which action should the level of 30% is a low level and would be re-
nurse take? ported to the health care provider because
it indicates blood loss; therefore options 2,
1- Report the abnormally low 3, and 4 are incorrect.
level.
2- Report the abnormally high
level.
3- Inform the client that the lab-
,Saunders NCLEX questions with 100% Verified Solutions | Graded A+
oratory result is normal.
4- Place the normal report in
the client's medical record.
4. A nurse provides dietary in- 2- Spinach
structions to a client who
will be taking warfarin sodium Warfarin sodium is an anticoagulant. Anti-
(Coumadin). The nurse should coagulant medications act by antagonizing
tell the client to avoid which the action of vitamin K, which is needed for
food item? clotting. When a client is taking an antico-
agulant, foods high in vitamin K often are
1- Grapes omitted from the diet. Vitamin K-rich foods
2-Spinach include green leafy vegetables, fish, liver,
3- Watermelon coffee, and tea.
4- Cottage cheese
5. A client who has been re- 2-Air embolism
ceiving total parenteral nu-
trition (TPN) by way of a The signs and symptoms of air embolism in-
central venous access de- clude chest pain, dyspnea, hypoxia, anxiety,
vice complains of chest pain tachycardia, and hypotension. The nurse
and dyspnea. The nurse quick- also may hear a loud churning sound
ly assesses the client's vital over the pericardium on auscultation of the
signs and notes that the pulse client's chest. The signs and symptoms of
rate has increased and the sepsis include fever, chills, and general
blood pressure has dropped. malaise. Fluid overload causes increased
The nurse determines that the intravascular volume, which increases the
client is most likely experienc- blood pressure and the pulse rate as the
ing which problem? heart tries to pump the extra fluid volume.
Fluid overload also causes neck vein dis-
1- Sepsis tention and shifting of fluid into the alveoli,
2- Air embolism resulting in lung crackles. The signs and
3- Fluid overload symptoms of a fluid imbalance depend on
4- Fluid imbalance the type of imbalance the client is experienc-
ing.
6. A client who is receiving intra- 1- Infection
venous (IV) fluid therapy com- 2-Phlebitis
plains of burning and a feeling 3-Infiltration
,Saunders NCLEX questions with 100% Verified Solutions | Graded A+
of tightness at the IV insertion 4-Thrombosis
site. On assessment, the nurse
detects coolness and swelling An infiltrated IV line is one that has dis-
at the site and notes that the lodged from the vein and is lying in subcuta-
IV rate has slowed. The nurse neous tissue. Pallor, coolness, and swelling
determines that which compli- at the IV site result when IV fluid is deposited
cation has occurred? in the subcutaneous tissue. When the pres-
sure 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 accom-
panied by warmth at the site, not coolness.
7. A nurse provides instructions 4-After maximal inspiration, hold the breath
to a preoperative client about for 10 seconds and then exhale.
the use of an incentive spirom-
eter. The nurse determines For optimal lung expansion with the incen-
that the client needs further in-tive spirometer, the client should assume a
struction if the client indicatessemi-Fowler's or high Fowler's position. The
that he or she will take which mouthpiece should be covered completely
action? and tightly while the client inhales slowly,
with a constant flow through the unit. When
1- Sit upright when using the maximal inspiration is reached, the client
device. should hold the breath for 2 or 3 seconds
2- Inhale slowly, maintaining a and then exhale slowly
constant flow.
3- Place the lips completely
over the mouthpiece.
4- After maximal inspiration,
hold the breath for 10 seconds
and then exhale.
8. The nurse is monitoring a 2- The chest tube is functioning as expected.
client who has a closed chest
tube drainage system. The The presence of fluctuation of the fluid level
nurse notes fluctuation of the in the water-seal chamber indicates a patent
fluid level in the water-seal drainage system. With normal breathing,
, Saunders NCLEX questions with 100% Verified Solutions | Graded A+
chamber during inspiration the water level rises with inspiration and falls
and expiration. On the basis of with expiration. Fluctuation stops if the tube
this finding, the nurse should is obstructed, if the suction is not working
make which interpretation? properly, or if the lung has re-expanded. Op-
tions 1, 3, and 4 are incorrect interpretations
1- There is a leak in the system. of the finding. An air leak may cause ex-
2- The chest tube is function- cessive bubbling in the water seal chamber.
ing as expected. Excessive and vigorous bubbling in the suc-
3- The amount of suction tion control chamber may indicate that the
needs to be decreased. amount of suction needs to be decreased.
4- The occlusive dressing at The status of the dressing is not specifically
the insertion site needs rein- related to the presence of fluctuation of the
forcement. fluid level in the water-seal chamber
9. A nurse is providing morn- 1- Call the health care provider.
ing care to a client who has
a closed chest tube drainage
system to treat a pneumoth- If the chest drainage system is dislodged
orax. When the nurse turns from the insertion site, the nurse immedi-
the client to the side, the ately applies sterile gauze over the site and
chest tube is accidentally calls the health care provider. The nurse
dislodged from the chest. would maintain the client in an upright po-
The nurse immediately applies sition. A new chest tube system may be at-
sterile gauze over the chest tached if the tube requires insertion, but this
tube insertion site. Which is would not be the next action. Pulse oxime-
the nurse's next action? try readings would assist in determining the
client's respiratory status, but the priority ac-
1- Call the health care provider. tion would be to call the health care provider
2- Replace the chest tube sys- in this emergency situation.
tem.
3- Obtain a pulse oximetry
reading.
4- Place the client in a Trende-
lenburg position
10. A nurse reviews the medica- 1- "Do you have any joint pain?"
tion history of a client and
notes that the client is tak- Leflunomide is an immunomodulatory agent
ing leflunomide (Arava). Dur- and has an anti-inflammatory action. The
