Saunders NCLEX RN NGN Newest 2025/2026 Version
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The nurse has given the client diagnosed with hepatitis
instructions about post discharge management during
convalescence. The nurse determines a need for further teaching
if the client makes which statement?
1."I should avoid alcohol and aspirin."
2."I should eat a high-carbohydrate, low-fat diet."
3."I should resume a full activity level within 1 week."
4."I should take the prescribed amounts of vitamin K." -
ANSWER-The client with hepatitis is easily fatigued and may
require several weeks to resume a full activity level. It is
important for the client to get adequate rest so that the liver may
heal. The client should take in a high-carbohydrate and low-fat
diet. The client should avoid hepatotoxic substances, such as
aspirin and alcohol. If prescribed for prolonged clotting times
the client should take vitamin K
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The nurse is checking a client's record for probable signs of
pregnancy. Which are the probable signs of pregnancy that the
nurse should note? Select all that apply. - ANSWER-The
probable signs of pregnancy include uterine enlargement;
Hegar's sign (the compressibility and softening of the lower
uterine segment that occurs at about week 6); Goodell's sign (the
softening of the cervix that occurs at the beginning of the second
month of pregnancy); Chadwick's sign (the violet coloration of
the mucous membranes of the cervix, vagina, and vulva that
occurs at about week 4); ballottement (the rebounding of the
fetus against the examiner's fingers on palpation); Braxton Hicks
contractions; and a positive pregnancy test that measures for
human chorionic gonadotropin. Positive signs of pregnancy
include a fetal heart rate that is detected by an electronic device
(Doppler transducer) at 10 to 12 weeks' gestation and by a
nonelectronic device (fetoscope) at 20 weeks' gestation; active
fetal movements that are palpable by the examiner; and an
outline of the fetus via radiography or ultrasound.
The nurse is monitoring the behavior of the client and
understands that the client with anorexia nervosa manages
anxiety by which action? - ANSWER-Clients with anorexia
nervosa have the desire to please others. Their need to be correct
or perfect interferes with rational decision-making processes.
These clients are moralistic. Rules and rituals help the clients
manage their anxiety.
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A client is receiving heparin sodium by continuous intravenous
(IV) infusion. The licensed practical nurse (LPN) is concerned
that the client received a bolus of medication when the tubing
was removed from the IV pump during a gown change. The
LPN immediately notifies the registered nurse or health care
provider and then checks to see whether which medication is
available in the medication supply area in case it is prescribed? -
ANSWER-If the tubing is removed from an IV pump and the
tubing is not clamped, the client will receive a bolus of the
solution and the medication contained in the solution. The client
who receives a bolus dose of heparin is at risk for bleeding. A
partial thromboplastin time (PTT) will be drawn and evaluated.
If the results of the PTT are too high, a dose of protamine
sulfate, the antidote for heparin, may be prescribed.
Aminocaproic acid is an antifibrinolytic (inhibits clot
breakdown). Enoxaparin is an anticoagulant. Vitamin K is the
antidote for warfarin sodium.
The nursing instructor has taught a lecture on the reproductive
cycle of the female and asks a nursing student to identify the
functions of the vagina. The student correctly responds by
identifying which functions? Select all that apply. - ANSWER-
The pelvis is a bony structure that supports and protects the
lower abdominal and internal reproductive organs. The vagina is
the female organ of coitus, allows discharge of the menstrual
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flow, and assists in the passage of the fetus from the uterus to
outside the mother's body during childbirth. The fallopian tubes
are lined with folded epithelium containing cilia that beat
rhythmically toward the uterine cavity to propel the ovum
through the tube. The functions of the ovaries include sex
hormone production and maturation of an ovum during each
reproductive cycle.
A client scheduled for a pulmonary angiography is fearful about
the procedure and asks the nurse if the procedure involves
significant pain and radiation exposure. The nurse gives a
response to the client that provides reassurance, based on which
understanding? - ANSWER-Pulmonary angiography involves
minimal exposure to radiation. The procedure is painless,
although the client may feel discomfort with insertion of the
needle for the catheter that is used for dye injection. No and
moderate pain and no exposure to radiation are incorrect.
The nurse prepares to administer digoxin to a 3-year-old with a
diagnosis of heart failure and notes that the apical heart rate is
120 beats per minute. Which nursing action is appropriate? -
ANSWER-The normal apical heart rate for a 3-year-old is 80 to
125 beats per minute. Because the apical heart rate is within
normal range, options 1, 3, and 4 are inappropriate.