NCLEX-RN Saunders Questions And Answers 2023 A+

NCLEX-RN Saunders Questions And Answers 2023 A+ * The nurse identifies low-risk therapies to a client & should include which therapy(s) in the discussion? Select all 1. Herbs 2. Prayer 3. Touch 4. Massage 5. Relaxation 6. Acupuncture - ANS-2, 3, 4, 5 * low risk therapies - have no adverse effects Which Pt(s) has a high risk of obesity & DM? Select all 1. 40 y.o Latino American M 2. 45 y.o native America M 3. 23 y.o Asian American F 4. 35 y.o Hispanic American M 5. 40 y.o African American F - ANS-1,2,4,5 Which meal tray should the RN deliver to a Pt with Orthodox Jew faith, who follows a kosher diet? 1. Pork roast, rice, veggies, mixed fruit, milk 2. Crab salad on a croissant, veggie with dip, potato salad, milk 3. Sweet & sour chicken with rice & veggie, mixed fruit, juice 4. Noodles & cream sauce with shrimp & veggie, salad, mixed fruit, iced tea - ANS-3 Dairy-meat combo is unacceptable; only fish that have scales & fins are allowed; meats that are allowed include animals that are veggie eaters, cloven-hoofed, & ritually slaughtered An anti hypertensive med has been RXed for HTN. The Pt tells the clinic nurse that they would like to take a herbal substance to help lower their BP. The nurse should take which action? 1. Tell the pt that herbal substances are not safe & should never be used. 2. Teach the Pt how to take their BP so it can be monitored closely. 3. Encourage the pt to discuss use of herbal substance with HCP - ANS-3 5 categories of complementary & alternative medicine (CAM) - ANS--Whole medical systems -Mind-body medicine -Biologically based practices -Manipulative & body-based practices -Energy medicine The RN notes presence of U waves on a pts cardiac monitor screen. What action(s) should the nurse take? - ANS-Cardiac changes in Hypokalemia include impaired repolarization, resulting in a flattened T wave & eventually the emergence of a U wave. The RN should suspect Hypokalemia. RN should: - assess VS & cardiac status for s/s of Hypokalemia (priority) - check pts most recent serum K level - contact HCP to report findings & obtain RXes to Tx hypokalemic state Hypovolemia - ANS-Fluid volume deficit Hypervolemia - ANS-Fluid volume excess *imp* hypoatremia precipitates lithium toxicity in a client taking _______? - ANS-Lithium (Lithobid) ECG changes in electrolyte imbalances: Hypocalcemia - ANS-Prolonged ST segment Prolonged QT interval ECG changes in electrolyte imbalances: Hypercalcemia - ANS-Shortened ST segment Widened T waves ECG changes in electrolyte imbalances: Hypokalemia - ANS-ST depression Shallow, flat, or inverted T wave Prominent U wave ECG changes in electrolyte imbalances: Hyperkalemia - ANS-Tall peaked T waves Flat P waves Widened QRS complex Prolonged PR interval ECG changes in electrolyte imbalances: Hypomagnesia - ANS-Tall T waves Depressed ST segment ECG changes in electrolyte imbalances: Hypermagnesemia - ANS-Prolonged PT interval Widened QRS complexes Potassium - ANS-Hypokalemia: 3.5 mEq/L -potentially life threatening bc every system is affected. *potassium is never admin IV push, IM, or SC route. IV potassium is always diluted & administered using an infusion device. Hyperkalemia:5.0 mEq/L *monitor serum potassium level closely when Pt receiving a potassium-retaining diuretic. Tests for hypocalcemia - ANS-1. Chostek's sign: a contraction of facial muscles in response to a light tap over the facial nerve in front of the ear. 2. Trousseau's sign: carpal spasm induced by inflating a BP cuff above the systolic pressure for a few minutes. Pt with Ca imbalance is at risk for? -Continues...