NCLEX RN Comprehensive B with NGN questions and answers with rationales graded A+

NCLEX RN Comprehensive B with NGN questions and answers with rationales graded A+ A nurse is assessing a client who is at 11 weeks of gestation and reports drinking ginger tea. Which of the following findings indicates the client's use of ginger tea is effective? The client reports a decrease in episodes of nausea. The client reports a decrease in breast tenderness. The client reports a decrease in headaches. The client reports a decrease in urinary frequency. - ANSWERThe client reports a decrease in episodes of nausea. RATIONALE-The nurse should realize that a decrease in the client's nausea indicates the ginger tea is effective. The client can also safely use ginger ale and ginger snaps to alleviate nausea associated with pregnancy. The nurse is continuing to care for the adolescent. Which of the following prescriptions should the nurse anticipate from the provider? For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the adolescent. Potential Prescription Prepare the adolescent for surgery. Remove the splint. Apply ice to the affected extremity. Elevate the right leg above heart level. - ANSWER-Anticipated Prepare the adolescent for surgery. Remove the splint. Contraindicated Apply ice to the affected extremity. Elevate the right leg above heart level. RATIONALE-When generating solutions for an adolescent who has compartment syndrome, the nurse should anticipate that the adolescent will need a fasciotomy. A fasciotomy is needed to decrease atrial spasms and increase perfusion within the muscle compartments. The nurse should recognize that elevating the right leg above heart level, and applying ice to the affected extremity are all contraindicated for an adolescent who has compartment syndrome. Elevating the right leg above heart level and applying ice to the affected extremity will further compromise blood flow. The nurse is continuing to care for the adolescent. The nurse is preparing the adolescent for the fasciotomy. Which of the following findings should the nurse report to the provider prior to surgery? The adolescent has not voided in 4 hr. The adolescent's blood pressure is 131/89 mm Hg. The adolescent's parents have concerns regarding the surgery. The adolescent reports severe pain. - ANSWER-The adolescent's parents have concerns regarding the surgery. RATIONALE-When taking actions for an adolescent who is scheduled for a fasciotomy, the nurse should notify the provider if the parents of the adolescent have questions or concerns regarding the procedure, which could indicate lack of understanding about the informed consent The nurse is assessing the adolescent 4 hr following fasciotomy. Click to highlight the findings below that indicate the adolescent's condition is improving. Adolescent is drowsy and reports nausea. Respirations shallow. Lungs clear. Unproductive cough present. S1 and S2 with regular rate and rhythm. Abdomen soft and nontender with hypoactive bowel sounds in all four quadrants. Right lower extremity fasciotomy, dressing clean, dry, and intact. Extremity pulse +3. Capillary refill 2 seconds. Right extremity is warm to the touch. Adolescent reports no numbness or tingling. Adolescent reports pain as 2 on a scale of 0 to 10. - ANSWER-Extremity pulse +3. Capillary refill 2 seconds. Right extremity is warm to the touch. Adolescent reports no numbness or tingling. Adolescent reports pain as 2 on a scale of 0 to 10. RATIONALE-When evaluating outcomes, the nurse should identify that the adolescent's extremity pulse, capillary refill, skin temperature, no reports of numbness or tingling, and a decrease in pain are all findings that indicate the fasciotomy was effective. A fasciotomy is a surgical procedure that creates an incision in the muscle fascia to relieve pressure within the compartment. The relief of the pressure restores perfusion to the area and reduces pain. A nurse is assessing a client who received 2 units of packed RBCs 48 hr ago. Which of the following findings should indicate to the nurse that the therapy has been effective? Hemoglobin 14.9 g/dL WBC count 12,000/mm3 Potassium 4.8 mEq/L BUN 18 mg/dL - ANSWER-Hemoglobin 14.9 g/dL RATIONALE-The nurse should identify that packed RBCs are administered to clients who have a decreased level of hemoglobin or hematocrit. This hemoglobin level is within the expected reference range of 14 to 18 g/dL for males and 12 to 16 g/dL for females, indicating the therapy has been effective.