Saunders NCLEX Questions And Answers 2023 A+

Saunders NCLEX Questions And Answers 2023 A+ The nurse has given the client diagnosed with hepatitis instructions about post discharge management during convalescence. The nurse determines a need for further teaching if the client makes which statement? 1."I should avoid alcohol and aspirin." 2."I should eat a high-carbohydrate, low-fat diet." 3."I should resume a full activity level within 1 week." 4."I should take the prescribed amounts of vitamin K." - ANS-The client with hepatitis is easily fatigued and may require several weeks to resume a full activity level. It is important for the client to get adequate rest so that the liver may heal. The client should take in a high-carbohydrate and low-fat diet. The client should avoid hepatotoxic substances, such as aspirin and alcohol. If prescribed for prolonged clotting times the client should take vitamin K The nurse is checking a client's record for probable signs of pregnancy. Which are the probable signs of pregnancy that the nurse should note? Select all that apply. - ANSThe probable signs of pregnancy include uterine enlargement; Hegar's sign (the compressibility and softening of the lower uterine segment that occurs at about week 6); Goodell's sign (the softening of the cervix that occurs at the beginning of the second month of pregnancy); Chadwick's sign (the violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 4); ballottement (the rebounding of the fetus against the examiner's fingers on palpation); Braxton Hicks contractions; and a positive pregnancy test that measures for human chorionic gonadotropin. Positive signs of pregnancy include a fetal heart rate that is detected by an electronic device (Doppler transducer) at 10 to 12 weeks' gestation and by a nonelectronic device (fetoscope) at 20 weeks' gestation; active fetal movements that are palpable by the examiner; and an outline of the fetus via radiography or ultrasound. The nurse is monitoring the behavior of the client and understands that the client with anorexia nervosa manages anxiety by which action? - ANS-Clients with anorexia nervosa have the desire to please others. Their need to be correct or perfect interferes with rational decision-making processes. These clients are moralistic. Rules and rituals help the clients manage their anxiety. A client is receiving heparin sodium by continuous intravenous (IV) infusion. The licensed practical nurse (LPN) is concerned that the client received a bolus of medication when the tubing was removed from the IV pump during a gown change. The LPN immediately notifies the registered nurse or health care provider and then checks to see whether which medication is available in the medication supply area in case it is prescribed? - ANS-If the tubing is removed from an IV pump and the tubing is not clamped, the client will receive a bolus of the solution and the medication contained in the solution. The client who receives a bolus dose of heparin is at risk for bleeding. A partial thromboplastin time (PTT) will be drawn and evaluated. If the results of the PTT are too high, a dose of protamine sulfate, the antidote for heparin, may be prescribed. Aminocaproic acid is an antifibrinolytic (inhibits clot breakdown). Enoxaparin is an anticoagulant. Vitamin K is the antidote for warfarin sodium. The nursing instructor has taught a lecture on the reproductive cycle of the female and asks a nursing student to identify the functions of the vagina. The student correctly responds by identifying which functions? Select all that apply. - ANS-The pelvis is a bony structure that supports and protects the lower abdominal and internal reproductive organs. The vagina is the female organ of coitus, allows discharge of the menstrual flow, and assists in the passage of the fetus from the uterus to outside the mother's body during childbirth. The fallopian tubes are lined with folded epithelium containing cilia that beat rhythmically toward the uterine cavity to propel the ovum through the tube. The functions of the ovaries include sex hormone production and maturation of an ovum during each reproductive cycle. A client scheduled for a pulmonary angiography is fearful about the procedure and asks the nurse if the procedure involves significant pain and radiation exposure. The nurse gives a response to the client that provides reassurance, based on which understanding? - ANS-Pulmonary angiography involves minimal exposure to radiation. The procedure is painless, although the client may feel discomfort with insertion of the needle for the catheter that is used for dye injection. No and moderate pain and no exposure to radiation are incorrect. The nurse prepares to administer digoxin to a 3-year-old with a diagnosis of heart failure and notes that the apical heart rate is 120 beats per minute. Which nursing action is appropriate? - ANS-The normal apical heart rate for a 3-year-old is 80 to 125 beats per minute. Because the apical heart rate is within normal range, options 1, 3, and 4 are inappropriate. The nurse is caring for a new postoperative client and is monitoring the client for signs of shock. The nurse monitors for which signs of this postoperative complication? - ANSPostoperative hypotension or shock can have numerous causes such as inadequate ventilation, side effects of anesthetic agents or preoperative medications, and fluid or blood loss. The symptoms of shock include hypotension; tachycardia; cold, moist, pale, or cyanotic skin; and increased restlessness and apprehension. A client receiving therapy with carbidopa/levodopa is upset and tells the nurse that his urine has turned a darker color since he began to take the medication. The client wants to discontinue its use. In formulating a response to the client's concerns, how does the nurse interpret this development? - ANS-With carbidopa/levodopa therapy, a darkening of the urine or sweat may occur. The client should be reassured that this is a harmless effect of the medication, and its use should be continued. Options 1, 2, and 4 are incorrect interpretations. A client newly diagnosed with chronic kidney disease will be receiving peritoneal dialysis. During the infusion of the dialysate, the client complains of abdominal pain. Which action by the nurse is appropriate? - ANS-Pain during the inflow of dialysate is common during the first few exchanges because of peritoneal irritation; however, it disappears after a week or two. The infusion amount should not be decreased, and the infusion should not be slowed or stopped. The nurse is initiating cardiopulmonary resuscitation on an adult client. The nurse should place the hands in which position to begin chest compressions? - ANS-Chest compressions are done by placing the hands on the lower half of the sternum. The locations in options 2, 3, and 4 would not provide effective chest compressions. The nurse is caring for a client who had a total knee replacement and was put on a continuous passive motion (CPM) machine in the postanesthesia care unit (PACU). What are some of the actions the nurse needs to monitor to operate this machine? Select all that apply. - ANS-While not as commonly used today, the CPM machine keeps the prosthetic knee in motion and may prevent the formation of scar tissue which could decrease knee mobility and increase postoperative pain. It should be used as much as the client can tolerate. The nurse needs to make sure that the machine is well padded and assess the client's response to the machine. Also, the machine needs to be turned off while the client is having a meal in bed. It is very important that the nurse ensures that the joint being moved is positioned properly on the machine. The cycle and range-of-motion settings must be checked every 8 hours and not once a day. When the machine is not in use, it should not be stored on the floor. If the client is confused, place the controls to the machine out of his or her reach. The client presents to the pediatrician's office with a temperature of 103° F for the past 3 days. The nurse also observes conjunctivitis without discharge, cracked lips, enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and enlarged nontender lymph nodes. Using situation, background, assessment, and recommendation (SBAR communication), which statements and/or questions should the nurse use in communication with the primary health care provider regarding this client's condition? Select all that apply. - ANS-Kawasaki's disease is a disease that affects the cardiovascular system leading to fever, oropharyngeal inflammation, enlarged lymph nodes, fissured lips, conjunctivitis, rash, peeling of palms and soles, irritability, and aneurysms. The nurse should communicate to the provider the situation, background, assessment, and recommendation (SBAR communication). The nurse should say, "This client is a 4-year-old male who presented to the clinic with a temperature of 103° F for the past 3 days. I observed this client to have conjunctivitis without discharge, cracked lips, enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and enlarged nontender lymph nodes. I am concerned this client has Kawasaki's disease. Can you please come assess this client? I think this client is at risk for aneurysm and thrombi development and should be taken to the hospital immediately." The nurse should not say, "It is most likely Kawasaki disease because it is the leading cause of acquired cardiovascular disease in the U.S." Although this statement is true, it is not necessary and should not be included in SBAR communication. The nurse is caring for a client who verbalizes a need to increase her self-esteem. Which action should the nurse plan to assist the client in achieving the goal of gaining self-esteem?...