Saunders Comprehensive Review For Nclex 2 - 2020 | Saunders Comprehensive Review For Nclex

SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX TWO 1)The nurse is providing discharge instructions to a Chinese American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. The nurse should implement which best action?  Answers-Continue with the instructions, verifying client understanding. 2) A critically ill Hispanic client tells the nurse through an interpreter that she is Roman Catholic and firmly believes in the rituals and traditions of the Catholic faith. Based on the client's statements, which actions by the nurse demonstrate cultural sensitivity and spiritual support? Select all that apply.(1,2,5)  Answers-Ensures that a close relative stays with the client  Makes a referral for a Catholic priest to visit the client  Offers to provide a means for praying the rosary if the client wishes. 3) Which clients have a high risk of obesity and diabetes mellitus? Select all that apply.(1,2,4,5) • Latino American Man • Native American man • Hispanic American man • African American woman 4) The nurse is preparing a plan of care for a client, and is asking the client about religious preferences. The nurse considers the client's religious preferences as being characteristic of a Jehovah's Witness if which client statement is made?  "I cannot have any food containing or prepared with blood." 5) The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior?  Answers-Reflecting a cultural value 6) When communicating with a client who speaks a different language, which best practice should the nurse implement?  Arrange for an interpreter to translate. 7) The nurse educator is providing in-service education to the nursing staff regarding transcultural nursing care; a staff member asks the nurse educator to provide an example of the concept of acculturation. The nurse educator should make which most appropriate response?  Answers-"A person who moves from China to the United States (U.S.) and learns about and adapts ato the culture in the U.S." 8) An Asin American client is experiencing a fever. The nurse plans care so that the client can self-treat the disorder using which method?  Foods considered to be yin 9) Which meal tray should the nurse deliver to a client of Orthodox Judaism faith who follows a kosher diet?  Sweet and sour chicken with rice and vegetables, mixed fruit, juice. 10) Which is the best nursing intervention regarding complementary and alternative medicine?  Educating the client about therapies that he or she is using or is interested in using 11) An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that he would like to take an herbal substance to help lower his blood pressure. The nurse should take which action?  Encourage the client to discuss the use of an herbal substance with the health care provider (HCP). 12) The nurse educator asks a student to list the 5 main categories of complementary and alternative medicine (CAM), developed by the National Center for Complementary and Alternative Medicine. Which statement, if made by the nursing student, indicates a need for further teaching regarding CAM categories?  "Magnetic therapy and massage therapy are a focus of CAM." 13) The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report?  The client was found lying on the floor. 14) A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action?  Transport the victim to the operating room for surgery. 15) The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next?  Reassess the client. 16) The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action?  Clarify with the team leader to make a safe ICU client assignment. 17) The nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse?  Call the nursing supervisor. 18) A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client?  "I will call the nursing supervisor to seek assistance regarding your request." 18) The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client's record to correct the error. The nurse should take which actions to correct the error? Select all that apply.  Document the correct information and end with the nurse's signature and title.  Draw 1 line through the error, initialing and dating it. 19) Which identifies accurate nursing documentation notations? Select all that apply.  The client slept through the night.  Abdominal wound dressing is dry and intact without drainage.  The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema. 20) A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right?  Observing care provided to the client without the client's permission 21) Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive personnel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the UAP that making this accusation has violated which legal tort? - - - - - - - -- - - - - - - - - - - -- - - - - - A client is taking Humulin NPH insulin and regular insulin every morning. The nurse should provide which instructions to the client? Select all that apply.  The home health care nurse is visiting a client who was recently diagnosed with type 2 diabetes mellitus. The client is prescribed repaglinide and metformin. The nurse should provide which instructions to the client? Select all that apply.  The nurse is teaching the client about his prescribed prednisone. Which statement, if made by the client, indicates that further teaching is necessary?  "I can take aspirin or my antihistamine if I need it." A client with hyperthyroidism has been given methimazole. Which nursing considerations are associated with this medication? Select all that apply.  Administer methimazole with food.  Assess the client for unexplained bruising or bleeding.  Instruct the client to report side and adverse effects such as sore throat, fever, or headaches. The nurse is monitoring a client receiving levothyroxine sodium for hypothyroidism. Which findings indicate the presence of a side effect associated with this medication? Select all that apply.  Insomnia  Weight loss  Mild heat intolerance The nurse provides instructions to a client who is taking levothyroxine. The nurse should tell the client to take the medication in which way?  On an empty stomach The nurse should tell the client, who is taking levothyroxine, to notify the health care provider (HCP) if which problem occurs?  Tremors The nurse is providing instructions to the client newly diagnosed with diabetes mellitus who has been prescribed pramlintide. Which instruction should the nurse include in the discharge teaching?  "Take your prescribed pills 1 hour before or 2 hours after the injection." The nurse teaches the client, who is newly diagnosed with diabetes insipidus, about the prescribed intranasal desmopressin. Which statements by the client indicate understanding? Select all that apply.  "I should decrease my oral fluids when I start this medication."  "I should report headache and drowsiness to my health care provider since these symptoms could be related to my desmopressin." A daily dose of prednisone is prescribed for a client. The nurse provides instructions to the client regarding administration of the medication and should instruct the client that which time is best to take this medication?  Early morning The client with hyperparathyroidism is taking alendronate. Which statements by the client indicate understanding of the proper way to take this medication? Select all that apply.  "I should sit up for at least 30 minutes after taking this medication."  "I should take this medication first thing in the morning on an empty stomach." A client with diabetes mellitus visits a health care clinic. The client's diabetes mellitus previously had been well controlled with glyburide daily, but recently the fasting blood glucose level has been 180 to 200 mg/dL (10.2 to 11.4 mmol/L). Which medication, if added to the client's regimen, may have contributed to the hyperglycemia?  Prednisone The nurse is monitoring a client admitted to the hospital with a diagnosis of appendicitis who is scheduled for surgery in 2 hours. The client begins to complain of increased abdominal pain and begins to vomit. On assessment, the nurse notes that the abdomen is distended and bowel sounds are diminished. Which is the most appropriate nursing intervention?  Notify the health care provider (HCP). A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? Select all that apply.  Gray-blue color at the flank  Abdominal guarding and tenderness  Left upper quadrant pain with radiation to the back The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations support this diagnosis? Select all that apply.  Fever  Complaints of indigestion  Pain in the upper right quadrant after a fatty meal A client is diagnosed with viral hepatitis, complaining of "no appetite" and "losing my taste for food." What instruction should the nurse give the client to provide adequate nutrition?  Increase intake of fluids, including juices. A client has developed hepatitis A after eating contaminated oysters. The nurse assesses the client for which expected assessment finding?  Malaise A client has just had a hemorrhoidectomy. Which nursing interventions are appropriate for this client? Select all that apply.  Administer stool softeners as prescribed.  Encourage a high-fiber diet to promote bowel movements without straining.  Apply cold packs to the anal-rectal area over the dressing until the packing is removed. The nurse is planning to teach a client with gastroesophageal reflux disease (GERD) about substances to avoid. Which items should the nurse include on this list? Select all that apply.  Coffee  Chocolate  Peppermint  Fried chicken A client has undergone esophagogastroduodenoscopy. The nurse should place highest priority on which item as part of the client's care plan?  Assessing for the return of the gag reflex The nurse has taught the client about an upcoming endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs further information if the client makes which statement?  "I'm glad I don't have to lie still for this procedure." The health care provider has determined that a client has contracted hepatitis A based on flulike symptoms and jaundice. Which statement made by the client supports this medical diagnosis?  "I ate shellfish about 2 weeks ago at a local restaurant." The nurse is providing dietary teaching for a client with a diagnosis of chronic gastritis. The nurse instructs the client to include which foods rich in vitamin B12 in the diet? Select all that apply.  Nuts  Liver  Lentils The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate?  Document the findings. The nurse is monitoring a client with a diagnosis of peptic ulcer. Which assessment finding would most likely indicate perforation of the ulcer?  A rigid, boardlike abdomen The nurse is caring for a client following a gastrojejunostomy (Billroth II procedure). Which postoperative prescription should the nurse question and verify?  Irrigating the nasogastric tube