Archer NCLEX questions and answers from lectures with verified solutions

Archer NCLEX questions and answers from lectures with verified solutions A 45-year-old man is rushed to the ER with reports of substernal chest pain and diaphoresis. cardiac troponin levels were taken and found to be elevated. the er nurse understands that nursing interventions would focus on which priority? a. increase oxygenation to the heart and reduce the hearts workload b. prevent complications and confirm a diagnosis of myocardial infarction c. alleviate the pts. anxiety - ANS- a A client has just been transferred back to this room following a below knee amputation of the right leg. the nurse is closely monitoring the client. which sign would prompt the nurse to assess further as it could indicates developing complication? a. client is growing increasingly restless b. client has a blood pressure of 187/78 mmHg. c. client has a pulse rate of 89bpm d. hypoactive bowel sounds were found upon auscultation of 4 quadrants - ANS- a A client in septic shock in the ICU is receiving a Dopamine infusion. Upon assessment, the nurse notices that the client's blood pressure is 195/120 mm Hg. which initial nursing action would the nurse implement? a. discontinue dopamine b. notify the physician c. administer furosemide d. assess the clients GCS - ANS- A client was admitted for pneumothorax and has received a chest tube attached to a three-chamber chest drainage system. at nighttime, the client has become disoriented, got out of bed, and has stepped on the drainage device causing it to break and lose its seal. Immediate nursing intervention should be: a. grab the forceps and clamp the chest tube proximal to the client's thorax. b. take the chest tube and attach it directly to the low wall suction c. keep the end of the chest tube sterile and contact the physician d. place the end of the chest tube in a container of sterile water - ANS- d A nurse is caring for a client receiving digoxin. the clients most recent serum digoxin level was 2.5ng/mL which of the following priority nursing actions should the nurse take? SATA a. withhold the clients scheduled dose b. administer the dose as prescribed c. assess the client's urinary output d. assess the clients most recent sodium level e. assess the clients heart rate and rhythm - ANS- a e A nurse is conducting preoperative teaching to a client who will undergo surgery in 1 week. which response by the client would prompt the nurse to give additional teaching? a. aspirin can possibly cause bleeding even after surgery b. aspiring can adversely affect my clotting ability. c. i should stop aspirin one day prior to my surgery d. it is important that i talk to my physician about the possibility of stopping aspirin before the surgery. - ANS- c A nurse is providing discharge instructions to a client with accelerated HTN who has been newly started on nifedipine. his home meds include calcium supplements for osteoporosis, omeprazole for heartburn, furosemide, and lisinopril Which statements by the client demonstrates the need for add'l teaching regarding nifedipine? SATA a. my gums may swell because of this medication b. i will avoid getting up too quickly from sitting or lying position c. it is highly likely that i will get constipated from this drug d. if i get a cough and tongue swelling i will hold nifedipine - ANS- a b a nurse is taking care of a client with severe burns. because of fluid shifting, the nurse knows tha the focus of attention is preventing hypovolemic shock. which is the best intervention to address this? a. administer dopamine as ordered b. applies medical antishock trousers c. infuse IV fluids are indicated d. infuse FFP - ANS- c A nurse is taking care of a client with severe burns. she knows that the patient is at risk for which of the following? a. hypovolemic shock b. distributive shock c. cardiogenic shock d. obstructive shock - ANS- a The client is admitted for having unstable angina. The nurse caring for the client understands that nitroglycerin should not be given to the client if he manifests which sign or symptom? a. atrial fibrillation b. a blood pressure of 78/59 mm Hg. c. headache d. a warm flushed feeling - ANS- b The nurse is answering phones in the general practice clinic and receives a call from a pt. who is experiencing leg pain after starting atorvastatin. which of the following instructions, when given by the nurse, is the best course of action? a. continue taking the medication as this is an expected side effect. b. discontinue the med and schedule an appt. for the next week. c. stretch for 20 minutes or take a warm shower d, discontinue the med and visit the clinic as soon as possible. - ANS- d The nurse is assigned to care for a patient with a chloride level of 90mEq/L. She knows that which of the following are causes of this electrolyte imbalance? SATA a. fluid volume excess b. Metabolic acidosis c. vomiting d. constipation - ANS- a c The nurse is caring for a client receiving morphine sulfate for severe pain. the nurse should implement all of the following actions except a. administer morphine only when the client complains of pain b. ensure naloxone is always available c. check the clients' respirations before giving morphine d, provide a high fiber diet - ANS- a The nurse is caring for a patient who has a chloride level of 115 mEq/L. Which of the following medications does she prepare to administer? (SATA) a. bicarbonate b. NS IVF c. LR IVF d. Lasix - ANS- a c The nurse is caring for a patient who has a serum calcium level of 13.2 mg/dL. Which of the following medication does she expect to administer? (SATA) a. Phosphorous b. calcitonin c. Vitamin D d. IV calcium gluconate - ANS- a b The nurse is caring for a patient whose most recent serum sodium level was 152 mEq/L. Which of the following signs and symptoms does she suspect are caused by the patients sodium level? SATA a. Lethargy b. Dry mucous membranes c. Tachypnea d. Cyanosis - ANS- a b The nurse is caring for a patient with a magnesium level of 1.1 mg/dL. Which of the following signs and symptoms does she closely monitor for? (SATA) a. Diarrhea b. Psychosis c. Tetany d. Decreased deep tendon reflexes - ANS- b c The nurse is caring for a patient with a phosphorous level of 5.0 mg/dL. she knows that which of the following are possible causes of this condition, (SATA) a. tumor lysis syndrome b. hypoparathyroidism c. hypercalcemia d renal failure - ANS- a b d The nurse is caring for a patient with a serum magnesium level of 3.2 mg/dL. She knows that which of the following could have caused the electrolyte abnormality? (SATA) a. Renal failure b. alcoholism c. anorexia d diarrhea - ANS- a The nurse is caring for a patient with a sodium level of 122 mEq/L. Which of the following assessment findings does she suspect? SATA a confusion b abdominal cramps c increased urine output d hypoactive bowel sounds - ANS- a b The nurse is caring for a pregnant client who is at 16 weeks' gestation. She developed a pulmonary embolism and was initiated on heparin therapy two days ago. she is getting ready to be discharged. Which of the following medications do you expect the healthcare provider to order at discharge? a. warfarin b. rivaroxaban c apixaban d low molecular weight heparin (LMWH) - ANS- D