Saunders NCLEX Comprehensive Review Study Questions And Answers.

Saunders NCLEX Comprehensive
Review Study Questions And Answers




A client admitted to the hospital with chest pain and a history of type 2 diabetes mellitus is scheduled for
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cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and
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for 48 hours after the procedure? - correct answers1.Glipizide
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2.Metformin***** e




3.Repaglinide e




4.Regular insulin e




A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The
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client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL.
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Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum
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creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the
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client is at risk for which problem? - correct answers1.Hypovolemia
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2.Acute kidney injury******* e e e




3.Glomerulonephritis e




4.Urinary tract infection e e




The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The
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PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64
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beats/minute. Which action should the nurse take? - correct answers1.Check vital signs.
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2.Check laboratory test results. e e e e

,3.Notify the health care provider. e e e e e




4.Continue to monitor for any rhythm change.******** e e e e e e




A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no
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electrocardiographic complexes on the screen. Which is the priority nursing action? - correct answers1.Call a e e e e e e e e e e e e e e e




code.

2.Call the health care provider.
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3.Check the client's status and lead placement.****** 4.Press the recorder button on the electrocardiogram
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console.



The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority? - correct
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answers1.Blood pressure
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2.Status of airway******* e e e




3.Oxygen flow rate e e e




4.Level of consciousnesse e




The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-
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defibrillator. The nurse should assess which item based on priority? - correct answers1. Anxiety level of the
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client and family e e




2.Presence of a MedicAlert card for the client to carry 3.Knowledge of restrictions on postdischarge physical
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activity e




4.Activation status of the device, heart rate cutoff, and number of shocks it is programmed to deliver*******
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A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats/minute. The PR interval is
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0.14 seconds, the QRS complex measures 0.08 seconds, and the PP and RR intervals are regular. How should
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the nurse correctly interpret this rhythm? - correct answers1.Sinus tachycardia******
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2.Sinus bradycardia e e




3.Sinus dysrhythmia e e




4.Normal sinus rhythm e e




The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours
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ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and
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edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret
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,the client's neurovascular status? - correct answers1. The neurovascular status is normal because of
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increased blood flow through the leg.******* e e e e e




2.The neurovascular status is moderately impaired, and the surgeon should be called.
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3.The neurovascular status is slightly deteriorating and should be monitored for another hour.
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4.The neurovascular status is adequate from an arterial approach, but venous complications are arising.
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The nurse is evaluating the condition of a client after pericardiocentesis performed to treat cardiac
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tamponade. Which observation would indicate that the procedure was effective? - correct answers1.
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Muffled heart sounds e e




e 2.

A rise in blood pressure******
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e 3.

Jugular venous distention e e




e 4.

Client expressions of dyspneae e e




A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which
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statement by the client indicates the need for further teaching? - correct answers1."I should notify my doctor
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if my feet or legs start to swell."
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2."My doctor told me to call his office if my pulse rate decreases below 60."
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3."Avoiding grapefruit juice will definitely be a challenge for me, since I usually drink it every morning with
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breakfast." e




4."My spouse told me that since I have developed this problem, we are going to stop walking in the mall every
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morning."*******



The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment
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finding indicates the presence of this complication? - correct answers1.Flat neck veins
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2.A pulse rate of 60 beats/minute
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3.Muffled or distant heart sounds**** e e e e




4.Wheezing on auscultation of the lungs e e e e e

, The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care
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management and self-care management. Which statement, if made by the client, indicates a need for further e e e e e e e e e e e e e e e e




instruction? - correct answers1."I need to be sure not to go barefoot around the house." e e e e e e e e e e e e e e e




2."If I cut my toenails, I need to be sure that I cut them straight across."
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3."It is all right to apply lanolin to my feet, but I shouldn't place it between my toes."
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4."I need to be sure that I elevate my leg above the level of my heart for at least an hour every day."********
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The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to
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be avoided. The nurse instructs the client to avoid consuming which item? - correct answers1.Bananas
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2.Broccoli

3.Antacids*******

4.Cantaloupe



The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse should plan to
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provide which instruction to the client? - correct answers1.Use nail polish to protect the nail beds from injury.
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2.Wear gloves for all activities involving the use of both hands.
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3.Stop smoking because it causes cutaneous blood vessel spasm. ********
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4.Always wear warm clothing, even in warm climates, to prevent vasoconstriction.
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The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over
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the varicosities as a result of secondary infection. Which is a priority intervention? - correct answers1.
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Keep the legs aligned with the heart.
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e 2.

Elevate the legs higher than the heart.*********
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e 3.

Clean the skin with alcohol every hour.
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e 4.

Position the client onto the side during every shift.e e e e e e e e




The nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from
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the intensive care unit (ICU). The nurse notes that a cardiac troponin T assay was performed while the client
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