Saunders NCLEX-PN
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1. 741. The nurse reinforces 741. 3
home care instructions to Rationale: Pertussis is transmitted by direct contact or respiratory
the parents of a child droplets from coughing. The communicable period occurs primarily
hospitalized with pertussis. during the catarrhal stage. Respiratory precautions are not required
The child is in the convales- during the convalescent phase. Options 1, 2, and 4 are components
cent stage and is being pre- of home care instructions.
pared for discharge. Which Test-Taking Strategy: Note the strategic words, need for further
statement by the parents teaching. These words indicate a negative event query and the
indicates a need for further need to select the incorrect statement. Options 1 and 4 can be
teaching? easily eliminated because they are general interventions associated
1. "We need to encourage with convalescence. Knowing that coughing spells are associated
adequate fluid intake." with pertussis will assist in directing you to the correct option from
2. "Coughing spells may the remaining options. In addition, a 2-week period of respiratory
be triggered by dust or precautions is not required. Review: home care instructions for the
smoke." child with pertussis.
3. "We need to main- Level of Cognitive Ability: Evaluating
tain respiratory precau- Client Needs: Safe and Effective Care Environment
tions and a quiet environ- Integrated Process: Nursing Process/Evaluation
ment for at least 2 weeks." Content Area: Child Health: Infectious and Communicable Diseases
4. "Good hand-washing Priority Concepts: Gas Exchange, Infection
techniques need to be in- Reference(s): Hockenberry, Wilson (2013), pp. 428, 653-654.
stituted to prevent spread-
ing the disease to others."
2. 742. A client enters 742. 1, 2, 3, 4, 5
the emergency depart- Rationale: Hypernatremia is described as having a serum sodium
ment confused, twitching, level that exceeds 145 mEq/L. Signs and symptoms would include
and having seizures. His dry mucous membranes, loss of skin turgor, thirst, flushed skin,
family states he recent- elevated temperature, oliguria, muscle twitching, fatigue, confusion,
ly was placed on corti- and seizures. Interventions include monitoring fluid balance, mon-
costeroids for arthritis and itoring vital signs, reducing dietary intake of sodium, monitoring
was feeling better and ex- electrolyte levels, and increasing oral intake of water. Sodium re-
, Saunders NCLEX-PN
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ercising daily. Upon as- placement therapy would not be prescribed for a client with hyper-
sessment, he has flushed natremia.
skin, dry mucous mem- Test-Taking Strategy: Focus on the subject, a sodium level of 172
branes, an elevated tem- mEq/L. Knowledge that this level is elevated and knowledge of the
perature, and poor skin treatment for hyperkalemia will direct you to the correct options.
turgor. His serum sodi- Review: hypernatremia.
um level is 172 mEq/L. Level of Cognitive Ability: Analyzing
Which interventions would Client Needs: Physiological Integrity
the health care provider Integrated Process: Nursing Process/Planning
likely prescribe? Select all Content Area: Fundamental Skills: Fluids & Electrolytes
that apply. Priority Concepts: Clinical Judgment, Fluid and Electrolyte Balance
1. Monitor the vital signs. Reference(s): deWit, Kumagai (2013), pp. 41-42.
2. Monitor intake and out-
put.
3. Increase water intake
orally.
4. Monitor the electrolyte
levels.
5. Provide a sodium-re-
duced diet.
6. Administer sodium re-
placements.
3. 743. The nurse is mon- 743. 4
itoring a client receiving Rationale: Glipizide (Glucotrol) is an oral hypoglycemic agent ad-
glipizide (Glucotrol). Which ministered to decrease the serum glucose level and the signs and
outcome indicates an inef- symptoms of hyperglycemia. Therefore, a decrease in both polyuria
fective response from the and polyphagia would indicate a therapeutic response. Laboratory
medication? values are also used to monitor a client's response to treatment. A
1. A decrease in polyuria fasting blood glucose level of 100 mg/dL is within normal limits.
2. A decrease in polypha- However, glycosylated hemoglobin of 12% indicates poor glycemic
gia control.
, Saunders NCLEX-PN
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3. A fasting plasma glucose Test-Taking Strategy: Focus on the subject, an ineffective response
of 100 mg/dL to the medication. Recalling that glipizide is an oral hypoglycemic
4. A glycosylated hemoglo- agent tells you to look for an option that would indicate hyper-
bin level of 12% glycemia (lack of response to the medication). Options 1 and 2 are
comparable or alike options and are eliminated first. Next, eliminate
option 3 because it is a normal blood glucose level. Review: glipizide
(Glucotrol).
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Pharmacology: Endocrine Medications
Priority Concepts: Adherence, Glucose Regulation
Reference(s): deWit, Kumagai (2013), pp. 827, 862.
4. 744. The nurse is reinforc- 744. 1
ing discharge instructions Rationale: Each dose of sulfisoxazole should be administered with a
to a client receiving sul- full glass of water, and the client should maintain a high fluid intake.
fisoxazole. Which should The medication is more soluble in alkaline urine. The client should
be included in the plan of not be instructed to taper or discontinue the dose. Some forms of
care for instructions? sulfisoxazole cause the urine to turn dark brown or red. This does
1. Maintain a high fluid in- not indicate the need to notify the health care provider.
take. Test-Taking Strategy: Focus on the subject, instructions for a client
2. Discontinue the medica- taking a sulfonamide. General principles related to medication ad-
tion when feeling better. ministration will assist in eliminating options 2 and 4. Options 2
3. If the urine turns dark and 4 are also comparable or alike options. Next, it is necessary
brown, call the health care to know that the client should maintain a high fluid intake. Review:
provider immediately. sulfisoxazole.
4. Decrease the dosage Level of Cognitive Ability: Applying
when symptoms are im- Client Needs: Physiological Integrity
proving to prevent an aller- Integrated Process: Teaching and Learning
gic response. Content Area: Pharmacology: Renal and Urinary Medications
, Saunders NCLEX-PN
Study online at https://quizlet.com/_3in306
Priority Concepts: Client Education, Elimination
Reference(s): deWit, Kumagai (2013), p.
5. 745. Before administering 745. 3
an intermittent tube feed- Rationale: All the stomach contents are aspirated and measured
ing through a nasogas- before administering a tube feeding. This procedure measures the
tric tube, the nurse checks gastric residual volume. The gastric residual volume is checked
for gastric residual volume. to confirm whether undigested formula from a previous feeding
Which is the best rationale remains and thereby evaluates the absorption of the last feeding.
for checking gastric resid- It is important to check the gastric residual before administration of
ual volume before adminis- a tube feeding. A full stomach could result in overdistention, thus
tering the tube feeding? predisposing the client to regurgitation and possible aspiration. If
1. Observe the digestion of residual feeding is obtained, the health care provider's prescription
formula. and agency policy are checked to determine the course of action
2. Check fluid and elec- (hold or reduce the volume of the intermittent tube feeding).
trolyte status. Test-Taking Strategy: Note the strategic word, best. Next, note the
3. Evaluate absorption of subject, the purpose of checking residual volume. Think about the
the last feeding. complications associated with tube feedings and the risk of as-
4. Confirm proper nasogas- piration with an overdistended stomach. Review: the purpose for
tric tube placement. checking gastric residual volume.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Adult Health: Gastrointestinal
Priority Concepts: Clinical Judgment, Nutrition
Reference(s): Cooper, Gosnell (2015), pp. 676, 680.
6. 746. A postoperative client 746. 2
requests medication for Rationale: Simethicone is an antiflatulent used in the relief of pain
flatulence (gas pains). caused by excessive gas in the gastrointestinal tract. Ondansetron
Which medication from the is used to treat postoperative nausea and vomiting. Acetaminophen
following PRN list should is a nonopioid analgesic. Magnesium hydroxide is an antacid and
Study online at https://quizlet.com/_3in306
1. 741. The nurse reinforces 741. 3
home care instructions to Rationale: Pertussis is transmitted by direct contact or respiratory
the parents of a child droplets from coughing. The communicable period occurs primarily
hospitalized with pertussis. during the catarrhal stage. Respiratory precautions are not required
The child is in the convales- during the convalescent phase. Options 1, 2, and 4 are components
cent stage and is being pre- of home care instructions.
pared for discharge. Which Test-Taking Strategy: Note the strategic words, need for further
statement by the parents teaching. These words indicate a negative event query and the
indicates a need for further need to select the incorrect statement. Options 1 and 4 can be
teaching? easily eliminated because they are general interventions associated
1. "We need to encourage with convalescence. Knowing that coughing spells are associated
adequate fluid intake." with pertussis will assist in directing you to the correct option from
2. "Coughing spells may the remaining options. In addition, a 2-week period of respiratory
be triggered by dust or precautions is not required. Review: home care instructions for the
smoke." child with pertussis.
3. "We need to main- Level of Cognitive Ability: Evaluating
tain respiratory precau- Client Needs: Safe and Effective Care Environment
tions and a quiet environ- Integrated Process: Nursing Process/Evaluation
ment for at least 2 weeks." Content Area: Child Health: Infectious and Communicable Diseases
4. "Good hand-washing Priority Concepts: Gas Exchange, Infection
techniques need to be in- Reference(s): Hockenberry, Wilson (2013), pp. 428, 653-654.
stituted to prevent spread-
ing the disease to others."
2. 742. A client enters 742. 1, 2, 3, 4, 5
the emergency depart- Rationale: Hypernatremia is described as having a serum sodium
ment confused, twitching, level that exceeds 145 mEq/L. Signs and symptoms would include
and having seizures. His dry mucous membranes, loss of skin turgor, thirst, flushed skin,
family states he recent- elevated temperature, oliguria, muscle twitching, fatigue, confusion,
ly was placed on corti- and seizures. Interventions include monitoring fluid balance, mon-
costeroids for arthritis and itoring vital signs, reducing dietary intake of sodium, monitoring
was feeling better and ex- electrolyte levels, and increasing oral intake of water. Sodium re-
, Saunders NCLEX-PN
Study online at https://quizlet.com/_3in306
ercising daily. Upon as- placement therapy would not be prescribed for a client with hyper-
sessment, he has flushed natremia.
skin, dry mucous mem- Test-Taking Strategy: Focus on the subject, a sodium level of 172
branes, an elevated tem- mEq/L. Knowledge that this level is elevated and knowledge of the
perature, and poor skin treatment for hyperkalemia will direct you to the correct options.
turgor. His serum sodi- Review: hypernatremia.
um level is 172 mEq/L. Level of Cognitive Ability: Analyzing
Which interventions would Client Needs: Physiological Integrity
the health care provider Integrated Process: Nursing Process/Planning
likely prescribe? Select all Content Area: Fundamental Skills: Fluids & Electrolytes
that apply. Priority Concepts: Clinical Judgment, Fluid and Electrolyte Balance
1. Monitor the vital signs. Reference(s): deWit, Kumagai (2013), pp. 41-42.
2. Monitor intake and out-
put.
3. Increase water intake
orally.
4. Monitor the electrolyte
levels.
5. Provide a sodium-re-
duced diet.
6. Administer sodium re-
placements.
3. 743. The nurse is mon- 743. 4
itoring a client receiving Rationale: Glipizide (Glucotrol) is an oral hypoglycemic agent ad-
glipizide (Glucotrol). Which ministered to decrease the serum glucose level and the signs and
outcome indicates an inef- symptoms of hyperglycemia. Therefore, a decrease in both polyuria
fective response from the and polyphagia would indicate a therapeutic response. Laboratory
medication? values are also used to monitor a client's response to treatment. A
1. A decrease in polyuria fasting blood glucose level of 100 mg/dL is within normal limits.
2. A decrease in polypha- However, glycosylated hemoglobin of 12% indicates poor glycemic
gia control.
, Saunders NCLEX-PN
Study online at https://quizlet.com/_3in306
3. A fasting plasma glucose Test-Taking Strategy: Focus on the subject, an ineffective response
of 100 mg/dL to the medication. Recalling that glipizide is an oral hypoglycemic
4. A glycosylated hemoglo- agent tells you to look for an option that would indicate hyper-
bin level of 12% glycemia (lack of response to the medication). Options 1 and 2 are
comparable or alike options and are eliminated first. Next, eliminate
option 3 because it is a normal blood glucose level. Review: glipizide
(Glucotrol).
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Pharmacology: Endocrine Medications
Priority Concepts: Adherence, Glucose Regulation
Reference(s): deWit, Kumagai (2013), pp. 827, 862.
4. 744. The nurse is reinforc- 744. 1
ing discharge instructions Rationale: Each dose of sulfisoxazole should be administered with a
to a client receiving sul- full glass of water, and the client should maintain a high fluid intake.
fisoxazole. Which should The medication is more soluble in alkaline urine. The client should
be included in the plan of not be instructed to taper or discontinue the dose. Some forms of
care for instructions? sulfisoxazole cause the urine to turn dark brown or red. This does
1. Maintain a high fluid in- not indicate the need to notify the health care provider.
take. Test-Taking Strategy: Focus on the subject, instructions for a client
2. Discontinue the medica- taking a sulfonamide. General principles related to medication ad-
tion when feeling better. ministration will assist in eliminating options 2 and 4. Options 2
3. If the urine turns dark and 4 are also comparable or alike options. Next, it is necessary
brown, call the health care to know that the client should maintain a high fluid intake. Review:
provider immediately. sulfisoxazole.
4. Decrease the dosage Level of Cognitive Ability: Applying
when symptoms are im- Client Needs: Physiological Integrity
proving to prevent an aller- Integrated Process: Teaching and Learning
gic response. Content Area: Pharmacology: Renal and Urinary Medications
, Saunders NCLEX-PN
Study online at https://quizlet.com/_3in306
Priority Concepts: Client Education, Elimination
Reference(s): deWit, Kumagai (2013), p.
5. 745. Before administering 745. 3
an intermittent tube feed- Rationale: All the stomach contents are aspirated and measured
ing through a nasogas- before administering a tube feeding. This procedure measures the
tric tube, the nurse checks gastric residual volume. The gastric residual volume is checked
for gastric residual volume. to confirm whether undigested formula from a previous feeding
Which is the best rationale remains and thereby evaluates the absorption of the last feeding.
for checking gastric resid- It is important to check the gastric residual before administration of
ual volume before adminis- a tube feeding. A full stomach could result in overdistention, thus
tering the tube feeding? predisposing the client to regurgitation and possible aspiration. If
1. Observe the digestion of residual feeding is obtained, the health care provider's prescription
formula. and agency policy are checked to determine the course of action
2. Check fluid and elec- (hold or reduce the volume of the intermittent tube feeding).
trolyte status. Test-Taking Strategy: Note the strategic word, best. Next, note the
3. Evaluate absorption of subject, the purpose of checking residual volume. Think about the
the last feeding. complications associated with tube feedings and the risk of as-
4. Confirm proper nasogas- piration with an overdistended stomach. Review: the purpose for
tric tube placement. checking gastric residual volume.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Adult Health: Gastrointestinal
Priority Concepts: Clinical Judgment, Nutrition
Reference(s): Cooper, Gosnell (2015), pp. 676, 680.
6. 746. A postoperative client 746. 2
requests medication for Rationale: Simethicone is an antiflatulent used in the relief of pain
flatulence (gas pains). caused by excessive gas in the gastrointestinal tract. Ondansetron
Which medication from the is used to treat postoperative nausea and vomiting. Acetaminophen
following PRN list should is a nonopioid analgesic. Magnesium hydroxide is an antacid and
