Saunders Comprehensive Review for the
NCLEX: Ch 69 Complex Care
856. A client had a 100 mL bag of 5% dextrose in 0.9% sodium chloride hung at
1500. The nurse making rounds at 1545 finds that the client is complaining of a
pounding headache and is dyspneic, experiencing chills, and apprehensive, with an
increased pulse rate. The intravenous bag (IV) has 400 mL remaining. The nurse
should take which action FIRST?
1. Slow the IV infusion
2. Sit the client up in bed
3. Remove the IV catheter
4. Call the primary health care provider (PHCP) - ANS-Answer: 1
Rationale: the client's symptoms are compatible with circulatory overload. This may
be verified by noting that 600mL has been infused in the course of 45 minutes. The
first action of the nurse is to slow the infusion. Other actions may be followed in rapid
sequence. The nurse may elevate the head of the bed to aid in the client's breathing
if necessary. The nurse also notifies the PCHP. The IV catheter is not removed; it
may be needed for the administration of medications to resolve the complication.
\857. Packed red blood cells have been prescribed for a female client with anemia
who has a hemoglobin level of 7.6 g/dL (76 mol/L) and a hematocrit level of 30%
(0.30). The nurse takes the client's temperature before the blood transfusion and
records 100.6 degrees Fahrenheit (38.1 degrees Celsius) orally. Which action should
the nurse take?
1. Begin the transfusion as prescribed
2. Administer an antihistamine and begin the transfusion
3. Administer 2 tablets of acetaminophen
4. Delay hanging the blood and notify the primary health care provider (PHCP) -
ANS-Answer: 4
Rationale: If the client has a temperature higher than 100 degrees F, the unit of blood
should not be hung until the PHCP is notified and has the opportunity to give further
instructions. The PHCP will likely prescribe that the blood be administered
regardless of the temperature or may instruct the nurse to administer prescribed
acetaminophen and wait until the temperature has decreased before administration,
but the decision is not within the nurse's scope of practice to make. The nurse needs
a PHCPs prescription to administer medication to the client.
\858. The nurse is caring for a client experiencing acute lower gastrointestinal
bleeding. In developing the plan of care, which priority problem should the nurse
assign to this client?
, 1. deficient fluid volume related to acute blood loss
2. risk for aspiration related to acute bleeding in the GI tract
3. risk for infection related to acute disease process and medications
4. Imbalanced nutrition, less than body requirements, related to lack of nutrients and
increased metabolism - ANS-Answer 1
Rationale: the priority problem for the client with a cute gastrointestinal bleeding
among these options is deficient fluid volume related to acute blood loss. This state
can result in decreased cardiac output and hypovolemic shock. Although nutrition is
a problem, fluid volume deficit is more of a priority. The client is at risk for aspiration
and infection, but these are not actual problems at this point in time.
\859. The nurse is assessing the functioning of a chest tube drainage system in a
client with a chest injury who has just returned from the recovery room following a
thoracotomy with wedge resection. SELECT ALL THAT APPLY
1. Excessive Bubbling in the water seal chamber
2. Vigorous bubbling in the suction control chamber
3. Drainage system maintained below the client's chest
4. 50mL of drainage in the drainage collection chamber
5. Occlusive dressing in place over the chest tube insertion site
6. Fluctuation of water in the tube in the water seal chamber during inhalation and
exhalation - ANS-Answer: 3,4,5,6
Rationale: the bubbling of water in the water seal chamber indicates air drainage
from the client and usually is seen when intrathoracic pressure is higher than
atmospheric pressure; it may occur during exhalation, coughing, or
sneezing.Excessive bubbling in the water seal chamber may indicate an air leak, an
unexpected finding. Fluctuation of water in the tube of water in the water seal
chamber during inhalation and exhalation is expected. An absence of fluctuation may
indicate that the chest tube is obstructed or that the lung has re-expanded and that
no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should
be noted in the suction control chamber. A total of 50 mL of drainage is not
excessive in a client retuning to the nursing unit from the recovery room. Drainage
that is more than 70 to 100 mL/hr is considered excessive and requires notification of
the surgeon. The chest tube insertion site is covered with an occlusive (airtight)
dressing to prevent air from entering the pleural space. Positioning the drainage
system below the client's chest allows gravity to drain the pleural system
\860. A client is brought to the emergency department with partial-thickness burns to
his face, neck, arms, and chest after trying to put out a car fire. The nurse should
implement which nursing actions for this client? SELECT ALL THAT APPLY
1. Restrict fluids
2.Assess for airway patency
3.Administer oxygen as prescribed
4.Place a cooling blanket on the client
NCLEX: Ch 69 Complex Care
856. A client had a 100 mL bag of 5% dextrose in 0.9% sodium chloride hung at
1500. The nurse making rounds at 1545 finds that the client is complaining of a
pounding headache and is dyspneic, experiencing chills, and apprehensive, with an
increased pulse rate. The intravenous bag (IV) has 400 mL remaining. The nurse
should take which action FIRST?
1. Slow the IV infusion
2. Sit the client up in bed
3. Remove the IV catheter
4. Call the primary health care provider (PHCP) - ANS-Answer: 1
Rationale: the client's symptoms are compatible with circulatory overload. This may
be verified by noting that 600mL has been infused in the course of 45 minutes. The
first action of the nurse is to slow the infusion. Other actions may be followed in rapid
sequence. The nurse may elevate the head of the bed to aid in the client's breathing
if necessary. The nurse also notifies the PCHP. The IV catheter is not removed; it
may be needed for the administration of medications to resolve the complication.
\857. Packed red blood cells have been prescribed for a female client with anemia
who has a hemoglobin level of 7.6 g/dL (76 mol/L) and a hematocrit level of 30%
(0.30). The nurse takes the client's temperature before the blood transfusion and
records 100.6 degrees Fahrenheit (38.1 degrees Celsius) orally. Which action should
the nurse take?
1. Begin the transfusion as prescribed
2. Administer an antihistamine and begin the transfusion
3. Administer 2 tablets of acetaminophen
4. Delay hanging the blood and notify the primary health care provider (PHCP) -
ANS-Answer: 4
Rationale: If the client has a temperature higher than 100 degrees F, the unit of blood
should not be hung until the PHCP is notified and has the opportunity to give further
instructions. The PHCP will likely prescribe that the blood be administered
regardless of the temperature or may instruct the nurse to administer prescribed
acetaminophen and wait until the temperature has decreased before administration,
but the decision is not within the nurse's scope of practice to make. The nurse needs
a PHCPs prescription to administer medication to the client.
\858. The nurse is caring for a client experiencing acute lower gastrointestinal
bleeding. In developing the plan of care, which priority problem should the nurse
assign to this client?
, 1. deficient fluid volume related to acute blood loss
2. risk for aspiration related to acute bleeding in the GI tract
3. risk for infection related to acute disease process and medications
4. Imbalanced nutrition, less than body requirements, related to lack of nutrients and
increased metabolism - ANS-Answer 1
Rationale: the priority problem for the client with a cute gastrointestinal bleeding
among these options is deficient fluid volume related to acute blood loss. This state
can result in decreased cardiac output and hypovolemic shock. Although nutrition is
a problem, fluid volume deficit is more of a priority. The client is at risk for aspiration
and infection, but these are not actual problems at this point in time.
\859. The nurse is assessing the functioning of a chest tube drainage system in a
client with a chest injury who has just returned from the recovery room following a
thoracotomy with wedge resection. SELECT ALL THAT APPLY
1. Excessive Bubbling in the water seal chamber
2. Vigorous bubbling in the suction control chamber
3. Drainage system maintained below the client's chest
4. 50mL of drainage in the drainage collection chamber
5. Occlusive dressing in place over the chest tube insertion site
6. Fluctuation of water in the tube in the water seal chamber during inhalation and
exhalation - ANS-Answer: 3,4,5,6
Rationale: the bubbling of water in the water seal chamber indicates air drainage
from the client and usually is seen when intrathoracic pressure is higher than
atmospheric pressure; it may occur during exhalation, coughing, or
sneezing.Excessive bubbling in the water seal chamber may indicate an air leak, an
unexpected finding. Fluctuation of water in the tube of water in the water seal
chamber during inhalation and exhalation is expected. An absence of fluctuation may
indicate that the chest tube is obstructed or that the lung has re-expanded and that
no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should
be noted in the suction control chamber. A total of 50 mL of drainage is not
excessive in a client retuning to the nursing unit from the recovery room. Drainage
that is more than 70 to 100 mL/hr is considered excessive and requires notification of
the surgeon. The chest tube insertion site is covered with an occlusive (airtight)
dressing to prevent air from entering the pleural space. Positioning the drainage
system below the client's chest allows gravity to drain the pleural system
\860. A client is brought to the emergency department with partial-thickness burns to
his face, neck, arms, and chest after trying to put out a car fire. The nurse should
implement which nursing actions for this client? SELECT ALL THAT APPLY
1. Restrict fluids
2.Assess for airway patency
3.Administer oxygen as prescribed
4.Place a cooling blanket on the client
