Saunders NCLEX questions
A 63-year-old woman whose husband died 2 months ago says to the visiting nurse,
"My daughter came over yesterday to help me move my husband's things out of our
bedroom, and I was so angry with her for moving his slippers from where he always
kept them under his side of our bed. She doesn't know how much I'm hurting." Which
statement by the nurse would be therapeutic?
1-"I know just how you feel because I lost my husband last summer."
2-"It's OK to grieve and be angry with your daughter and anyone else for a time."
3-"You need to focus on the many good years you both enjoyed together and move
on."
4-"Although it's a troubling time for you, try to focus on your children and
grandchildren." - ANS-2-"It's OK to grieve and be angry with your daughter and
anyone else for a time."
The therapeutic statement is the one that gives the client permission to grieve and
acknowledges that anger is part of loss and that it may be aimed at the people who
are trying most to help and are closest. Options 1, 3, and 4 are all nontherapeutic.
They do not encourage the client to express feelings.
\A child seen in the clinic is found to have rubeola (measles), and the mother asks
the nurse how to care for the child. The nurse should tell the mother to implement
which action?
1-Keep the child in a room with dim lights.
2-Give the child warm baths to help prevent itching.
3-Allow the child to play outdoors because sunlight will help the rash.
4-Take the child's temperature every 4 hours and administer 1 baby aspirin for fever.
- ANS-1-Keep the child in a room with dim lights.
A nursing consideration in rubeola is eye care. The child usually has photophobia, so
the nurse should suggest that the parent keep the child out of brightly lit areas. Warm
baths and sunlight will aggravate itching. Additionally, the child needs to rest.
Children with viral infections are not to be given aspirin because of the risk of Reye's
syndrome.
\A client has a prescription for continuous monitoring of oxygen saturation by pulse
oximetry for a preoperative client. The nurse should perform which best action to
ensure accurate readings on the oximeter?
1-Apply the sensor to a finger that is cool to the touch.
2-Apply the sensor to a finger with very dark nail polish.
,3-Ask the client to limit motion in the hand attached to the pulse oximeter.
4-Place the sensor distal to an intravenous (IV) site with a continuous IV infusion. -
ANS-3-Ask the client to limit motion in the hand attached to the pulse oximeter.
Several factors can interfere with the reading of accurate oxygen saturation levels on
a pulse oximeter. To ensure accurate readings, the nurse should ask the client to
limit motion of the area attached to the sensor. The nurse should apply the device to
a warm area because hypotension, hypothermia, and vasoconstriction interfere with
blood flow to the area. The nurse needs to know that very dark nail polish (black,
brown-red, blue, green) interferes with accurate measurement. The nurse also
should avoid placing the sensor distal to any invasive arterial or venous catheters,
pressure dressings, or blood pressure cuffs.
\A client in the postpartum unit complains of sudden, sharp chest pain. The client is
tachycardic, and the respiratory rate is increased. The health care provider
diagnoses a pulmonary embolism. Which actions should the nurse plan to take?
Select all that apply.
1-Administer oxygen.
2-Assess the blood pressure.
3-Start an intravenous (IV) line.
4-Prepare to administer morphine sulfate.
5-Place the client on bed rest in a supine position.
6-Prepare to administer warfarin sodium (Coumadin). - ANS-1-Administer oxygen.
2-Assess the blood pressure.
3-Start an intravenous (IV) line.
4-Prepare to administer morphine sulfate
If pulmonary embolism is suspected, oxygen is administered to decrease hypoxia.
The client also is kept on bed rest, with the head of the bed slightly elevated to
reduce dyspnea. Morphine sulfate may be prescribed for the client to reduce pain
and apprehension. An IV line also will be required, and vital signs must be
monitored. Heparin therapy (not warfarin sodium) is administered.
\A client is found to have rape trauma syndrome. The nurse plans care for the client
knowing that which occurs in this condition?
1-More than one assault
2-Re-experiencing recollections of the trauma
3-Actively initiating situations in which sex is forced
4-Imagining the use of foreign objects in a sexual situation - ANS-2-Re-experiencing
recollections of the trauma
The major trauma of rape or sexual assault involves the victim's emotional reaction
to being physically forced to do something against his or her will. The life-threatening
nature of the crime and feelings of helplessness, loss of control, and experiencing
, the self as an object of the perpetrator's rage combine to produce the victim's
overpowering fear and stress. In this syndrome, which has been called rape trauma
syndrome, the client re-experiences the trauma, as evidenced by recurrent
recollections of the event. Options 1, 3, and 4 are not associated with rape trauma
syndrome.
\A client is taking ticlopidine hydrochloride (Ticlid). The nurse should tell the client to
avoid which substance while taking this medication?
1-Vitamin C
2-Vitamin D
3-Acetaminophen (Tylenol)
4-Acetylsalicylic acid (aspirin) - ANS-4-Acetylsalicylic acid (aspirin)
Ticlopidine hydrochloride is a platelet aggregation inhibitor. It is used to decrease the
risk of thrombotic stroke in clients with precursor symptoms. Because it is an
antiplatelet agent, other medications that precipitate or aggravate bleeding should be
avoided during its use. Therefore, aspirin or any aspirin-containing product should be
avoided. The substances in options 1, 2, and 3 are safe to consume.
\A client who has been hospitalized with a paranoid disorder refuses to turn off the
lights in the room at night and states, "My roommate will steal me blind." Which is the
appropriate response by the nurse?
1-"Why do you believe this?"
2-"Tell me more about the details of your belief."
3-"I hear what you are saying, but I don't share your belief."
4-"If you want a pass for tomorrow evening's movie, you'd better turn that light off
this minute." - ANS-3-"I hear what you are saying, but I don't share your belief."
Paranoid beliefs are coping mechanisms used by the client and therefore are not
easily relinquished. It is important not to support the belief and not to ridicule, argue,
or criticize it. Option 1 places the client in a defensive position by asking "why."
Option 2 encourages the client to expound on the belief when discussion should
instead be limited. Option 4 threatens the client.
\A client who has been receiving total parenteral nutrition (TPN) by way of a central
venous access device complains of chest pain and dyspnea. The nurse quickly
assesses the client's vital signs and notes that the pulse rate has increased and the
blood pressure has dropped. The nurse determines that the client is most likely
experiencing which problem?
1-Sepsis
2-Air embolism
3-Fluid overload
4-Fluid imbalance - ANS-2-Air embolism
A 63-year-old woman whose husband died 2 months ago says to the visiting nurse,
"My daughter came over yesterday to help me move my husband's things out of our
bedroom, and I was so angry with her for moving his slippers from where he always
kept them under his side of our bed. She doesn't know how much I'm hurting." Which
statement by the nurse would be therapeutic?
1-"I know just how you feel because I lost my husband last summer."
2-"It's OK to grieve and be angry with your daughter and anyone else for a time."
3-"You need to focus on the many good years you both enjoyed together and move
on."
4-"Although it's a troubling time for you, try to focus on your children and
grandchildren." - ANS-2-"It's OK to grieve and be angry with your daughter and
anyone else for a time."
The therapeutic statement is the one that gives the client permission to grieve and
acknowledges that anger is part of loss and that it may be aimed at the people who
are trying most to help and are closest. Options 1, 3, and 4 are all nontherapeutic.
They do not encourage the client to express feelings.
\A child seen in the clinic is found to have rubeola (measles), and the mother asks
the nurse how to care for the child. The nurse should tell the mother to implement
which action?
1-Keep the child in a room with dim lights.
2-Give the child warm baths to help prevent itching.
3-Allow the child to play outdoors because sunlight will help the rash.
4-Take the child's temperature every 4 hours and administer 1 baby aspirin for fever.
- ANS-1-Keep the child in a room with dim lights.
A nursing consideration in rubeola is eye care. The child usually has photophobia, so
the nurse should suggest that the parent keep the child out of brightly lit areas. Warm
baths and sunlight will aggravate itching. Additionally, the child needs to rest.
Children with viral infections are not to be given aspirin because of the risk of Reye's
syndrome.
\A client has a prescription for continuous monitoring of oxygen saturation by pulse
oximetry for a preoperative client. The nurse should perform which best action to
ensure accurate readings on the oximeter?
1-Apply the sensor to a finger that is cool to the touch.
2-Apply the sensor to a finger with very dark nail polish.
,3-Ask the client to limit motion in the hand attached to the pulse oximeter.
4-Place the sensor distal to an intravenous (IV) site with a continuous IV infusion. -
ANS-3-Ask the client to limit motion in the hand attached to the pulse oximeter.
Several factors can interfere with the reading of accurate oxygen saturation levels on
a pulse oximeter. To ensure accurate readings, the nurse should ask the client to
limit motion of the area attached to the sensor. The nurse should apply the device to
a warm area because hypotension, hypothermia, and vasoconstriction interfere with
blood flow to the area. The nurse needs to know that very dark nail polish (black,
brown-red, blue, green) interferes with accurate measurement. The nurse also
should avoid placing the sensor distal to any invasive arterial or venous catheters,
pressure dressings, or blood pressure cuffs.
\A client in the postpartum unit complains of sudden, sharp chest pain. The client is
tachycardic, and the respiratory rate is increased. The health care provider
diagnoses a pulmonary embolism. Which actions should the nurse plan to take?
Select all that apply.
1-Administer oxygen.
2-Assess the blood pressure.
3-Start an intravenous (IV) line.
4-Prepare to administer morphine sulfate.
5-Place the client on bed rest in a supine position.
6-Prepare to administer warfarin sodium (Coumadin). - ANS-1-Administer oxygen.
2-Assess the blood pressure.
3-Start an intravenous (IV) line.
4-Prepare to administer morphine sulfate
If pulmonary embolism is suspected, oxygen is administered to decrease hypoxia.
The client also is kept on bed rest, with the head of the bed slightly elevated to
reduce dyspnea. Morphine sulfate may be prescribed for the client to reduce pain
and apprehension. An IV line also will be required, and vital signs must be
monitored. Heparin therapy (not warfarin sodium) is administered.
\A client is found to have rape trauma syndrome. The nurse plans care for the client
knowing that which occurs in this condition?
1-More than one assault
2-Re-experiencing recollections of the trauma
3-Actively initiating situations in which sex is forced
4-Imagining the use of foreign objects in a sexual situation - ANS-2-Re-experiencing
recollections of the trauma
The major trauma of rape or sexual assault involves the victim's emotional reaction
to being physically forced to do something against his or her will. The life-threatening
nature of the crime and feelings of helplessness, loss of control, and experiencing
, the self as an object of the perpetrator's rage combine to produce the victim's
overpowering fear and stress. In this syndrome, which has been called rape trauma
syndrome, the client re-experiences the trauma, as evidenced by recurrent
recollections of the event. Options 1, 3, and 4 are not associated with rape trauma
syndrome.
\A client is taking ticlopidine hydrochloride (Ticlid). The nurse should tell the client to
avoid which substance while taking this medication?
1-Vitamin C
2-Vitamin D
3-Acetaminophen (Tylenol)
4-Acetylsalicylic acid (aspirin) - ANS-4-Acetylsalicylic acid (aspirin)
Ticlopidine hydrochloride is a platelet aggregation inhibitor. It is used to decrease the
risk of thrombotic stroke in clients with precursor symptoms. Because it is an
antiplatelet agent, other medications that precipitate or aggravate bleeding should be
avoided during its use. Therefore, aspirin or any aspirin-containing product should be
avoided. The substances in options 1, 2, and 3 are safe to consume.
\A client who has been hospitalized with a paranoid disorder refuses to turn off the
lights in the room at night and states, "My roommate will steal me blind." Which is the
appropriate response by the nurse?
1-"Why do you believe this?"
2-"Tell me more about the details of your belief."
3-"I hear what you are saying, but I don't share your belief."
4-"If you want a pass for tomorrow evening's movie, you'd better turn that light off
this minute." - ANS-3-"I hear what you are saying, but I don't share your belief."
Paranoid beliefs are coping mechanisms used by the client and therefore are not
easily relinquished. It is important not to support the belief and not to ridicule, argue,
or criticize it. Option 1 places the client in a defensive position by asking "why."
Option 2 encourages the client to expound on the belief when discussion should
instead be limited. Option 4 threatens the client.
\A client who has been receiving total parenteral nutrition (TPN) by way of a central
venous access device complains of chest pain and dyspnea. The nurse quickly
assesses the client's vital signs and notes that the pulse rate has increased and the
blood pressure has dropped. The nurse determines that the client is most likely
experiencing which problem?
1-Sepsis
2-Air embolism
3-Fluid overload
4-Fluid imbalance - ANS-2-Air embolism
