Saunders Comprehensive Review For Nclex 1 - 2020 | Saunders Comprehensive Review For Nclex

SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX ONE {2020} 1000+ questions and answers 1) The nurse is providing discharge instructions to a Chinese American client regarding prescribed dietary modifications. During the teaching session, the client continuously turns away from the nurse. The nurse should implement which best action?  Answers-Continue with the instructions, verifying client understanding. 1) A critically ill Hispanic client tells the nurse through an interpreter that she is Roman Catholic and firmly believes in the rituals and traditions of the Catholic faith. Based on the client's statements, which actions by the nurse demonstrate cultural sensitivity and spiritual support? Select all that apply.(1,2,5)  Answers-Ensures that a close relative stays with the client  Makes a referral for a Catholic priest to visit the client  Offers to provide a means for praying the rosary if the client wishes. 2) Which clients have a high risk of obesity and diabetes mellitus? Select all that apply.(1,2,4,5)  Latino American Man  Native American man  Hispanic American man  African American woman 3) The nurse is preparing a plan of care for a client, and is asking the client about religious preferences. The nurse considers the client's religious preferences as being characteristic of a Jehovah's Witness if which client statement is made?  I cannot have any food containing or Prepared with blood." 4) The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior?  Answers-Reflecting a cultural value 5) When communicating with a client who speaks a different language, which best practice should the nurse implement?  Arrange for an interpreter to translate. 6) The nurse educator is providing in-service education to the nursing staff regarding transcultural nursing care; a staff member asks the nurse educator to provide an example of the concept of acculturation. The nurse educator should make which most appropriate response?  Answers-"A person who moves from China to the United States (U.S.) and learns about and adapts ato the culture in the U.S." 7) An Asin American client is experiencing a fever. The nurse plans care so that the client can self-treat the disorder using which method?  Foods considered to be yin 8) Which meal tray should the nurse deliver to a client of Orthodox Judaism faith who follows a kosher diet?  Sweet and sour chicken with rice and vegetables, mixed fruit, juice. 9) Which is the best nursing intervention regarding complementary and alternative medicine?  Educating the client about therapies that he or she is using or is interested in using 10) An antihypertensive medication has been prescribed for a client with hypertension. The client tells the clinic nurse that he would like to take an herbal substance to help lower his blood pressure. The nurse should take which action?  Encourage the client to discuss the use of an herbal substance with the health care provider (HCP). 11) The nurse educator asks a student to list the 5 main categories of complementary and alternative medicine (CAM), developed by the National Center for Complementary and Alternative Medicine. Which statement, if made by the nursing student, indicates a need for further teaching regarding CAM categories?  "Magnetic therapy and massage therapy are a focus of CAM." 12) The nurse hears a client calling out for help, hurries down the hallway to the client's room, and finds the client lying on the floor. The nurse performs an assessment, assists the client back to bed, notifies the health care provider of the incident, and completes an incident report. Which statement should the nurse document on the incident report?  The client was found lying on the floor. 13) A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action?  Transport the victim to the operating room for surgery. 14) The nurse has just assisted a client back to bed after a fall. The nurse and health care provider have assessed the client and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next?  Reassess the client. 15) The nurse arrives at work and is told to report (float) to the intensive care unit (ICU) for the day because the ICU is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the ICU. The nurse should take which best action?  Clarify with the team leader to make a safe ICU client assignment. 16) The nurse who works on the night shift enters the medication room and finds a co-worker with a tourniquet wrapped around the upper arm. The co-worker is about to insert a needle, attached to a syringe containing a clear liquid, into the antecubital area. Which is the most appropriate action by the nurse?  Call the nursing supervisor. 17) A hospitalized client tells the nurse that an instructional directive is being prepared and that the lawyer will be bringing the document to the hospital today for witness signatures. The client asks the nurse for assistance in obtaining a witness to the will. Which is the most appropriate response to the client?  "I will call the nursing supervisor to seek assistance regarding your request." 19) The nurse has made an error in a narrative documentation of an assessment finding on a client and obtains the client's record to correct the error. The nurse should take which actions to correct the error? Select all that apply.  Document the correct information and end with the nurse's signature and title.  Draw 1 line through the error, initialing and dating it. 20) Which identifies accurate nursing documentation notations? Select all that apply.  The client slept through the night.  Abdominal wound dressing is dry and intact without drainage.  The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema. 21) A nursing instructor delivers a lecture to nursing students regarding the issue of client's rights and asks a nursing student to identify a situation that represents an example of invasion of client privacy. Which situation, if identified by the student, indicates an understanding of a violation of this client right?  Observing care provided to the client without the client's permission 22) Nursing staff members are sitting in the lounge taking their morning break. An unlicensed assistive personnel (UAP) tells the group that she thinks that the unit secretary has acquired immunodeficiency syndrome (AIDS) and proceeds to tell the nursing staff that the secretary probably contracted the disease from her husband, who is supposedly a drug addict. The registered nurse should inform the UAP that making this accusation has violated which legal tort?  Slander 23) An 87-year-old woman is brought to the emergency department for treatment of a fractured arm. On physical assessment, the nurse notes old and new ecchymotic areas on the client's chest and legs and asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her son frequently hits her if supper is not prepared on time when he arrives home from work. Which is the most appropriate nursing response?  As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay." 24) The nurse calls the heath care provider (HCP) regarding a new medication prescription because the dosage prescribed is higher than the recommended dosage. The nurse is unable to locate the HCP, and the medication is due to be administered. Which action should the nurse take?  Contact the nursing supervisor. 25) The nurse employed in a hospital is waiting to receive a report from the laboratory via the facsimile (fax) machine. The fax machine activates and the nurse expects the report, but instead receives a sexually oriented photograph. Which is the most appropriate initial nursing action?  Call the nursing supervisor and report the incident. 26) The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?  A client with asthma who requested a breathing treatment during the previous shift 27) The nurse employed in an emergency department is assigned to triage clients coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client?  A client with chest pain who states that he just ate pizza that was made with a very spicy sauce 28) A nursing graduate is attending an agency orientation regarding the nursing model of practice implemented in the health care facility. The nurse is told that the nursing model is a team nursing approach. The nurse determines that which scenario is characteristic of the team-based model of nursing practice? - - - - - - - - - - -- - - - - - - - - -967) To perform cardiopulmonary resuscitation (CPR), the nurse should use the method pictured to open the airway in which situation? Refer to figure. View Figure  If neck trauma is suspected 968) The nurse teaches skin care to a client receiving external radiation therapy. Which client statement indicates the need for further instruction?  "I will limit sun exposure to 1 hour daily." 969) The health care provider's prescription reads 100 mcg of a medication orally daily. The medication label reads 0.1 mg per tablet. The nurse should administer how many tablet(s) to the client? Fill in the blank.  Correct Answer: 1.5 tablet(s) 970) Metformin is prescribed for a client with type 2 diabetes mellitus. What is the most common side effect that the nurse should include in the client's teaching plan?  Gastrointestinal disturbances 971) Which nursing actions apply to the care of a child who is having a seizure? Select all that apply.  Time the seizure.  Stay with the child.  Loosen clothing around the child's neck.  Place the child in a lateral side-lying position. 972) The nurse is conducting an interview of an older client and is concerned about the possibility of benign prostatic hyperplasia (BPH). Which are characteristics of this disorder? Select all that apply.  Nocturia  Incontinence  Enlarged prostate 973) The nursing instructor asks a nursing student to identify the priorities of care for an assigned client. Which statement indicates that the student correctly identifies the priority client needs?  Actual or life-threatening concerns 974) A client arrives at the clinic complaining of fatigue, lack of energy, constipation, and depression. Hypothyroidism is diagnosed, and levothyroxine is prescribed. What is an expected outcome of the medication?  Achieve normal thyroid hormone levels 975) The community health nurse is creating a poster for an educational session for a group of women and will be discussing the risk factors associated with breast cancer. Which risk factors for breast cancer should the nurse list on the poster? Select all that apply.  Early menarc  Family history of breast cancer  High-dose radiation exposure to chest  Previous cancer of the breast, uterus, or ovaries 976) The nurse is caring for a client with acute pancreatitis and is monitoring the client for paralytic ileus. Which piece of assessment data should alert the nurse to this occurrence?  Inability to pass flatus 977) The nurse inspects the color of the drainage from a nasogastric tube on a postoperative client approximately 24 hours after gastric surgery. Which finding indicates the need to notify the health care provider (HCP)?  Dark red drainage 978) The nurse is preparing to discontinue a client's nasogastric tube. The client is positioned properly, and the tube has been flushed with 15 mL of air to clear secretions. Before removing the tube, the nurse should make which statement to the client?  "Take a deep breath when I tell you, and hold it while I remove the tube." 979) A client with a history of lung disease is at risk for developing respiratory acidosis. The nurse should assess the client for which signs and symptoms characteristic of this disorder?  Headache, restlessness, and confusion 980) The nurse is caring for a client with a resolved intestinal obstruction who has a nasogastric tube in place. The health care provider has now prescribed that the nasogastric tube be removed. What is the priority nursing assessment prior to removing the tube?  Headache, restlessness, and confusion 981) The nurse has reviewed with the preoperative client the procedure for the administration of an enema. Which statement by the client would indicate the need for further instruction  Checking for the presence of bowel sounds in all 4 quadrants 982) A client experiencing a great deal of stress and anxiety is being taught to use self-control therapy. Which statement by the client indicates a need for further teaching about the therapy?  "The enema will be given while I am sitting on the toilet." 983) The nurse is preparing a list of home care instructions regarding stoma and laryngectomy care for a client with laryngeal cancer who had a laryngectomy. Which instructions should be included in the list? Select all that apply.  "This form of therapy provides a negative reinforcement when the stimulus is produced." 984) The health care provider prescribes 2000 mL of 5% dextrose and half-normal saline to infuse over 24 hours. The drop factor is 15 drops (gtt)/mL. The nurse should set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.  Obtain a MedicAlert bracelet.  Prevent debris from entering the stoma.  Avoid exposure to people with infections.  Avoid swimming and use care when showering. 985) A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect?  Correct Answer: 21 gtt/min 986) A client has had radical neck dissection and begins to hemorrhage at the incision site. The nurse should take which actions in this situation? Select all that apply.  Monitor vital signs.  Monitor the client's airway.  Apply manual pressure over the site.  Call the health care provider (HCP) immediately. 987) A sexually active young adult client has developed viral hepatitis. Which client statement indicates the need for further teaching?  "I can go back to work right away." 988) The nurse should include which interventions in the plan of care for a client with hypothyroidism? Select all that apply.  Instruct the client about thyroid replacement therapy.  Encourage the client to consume fluids and high-fiber foods in the diet.  Instruct the client to contact the health care provider (HCP) if episodes of chest pain occur. 989) The nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. The nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. Which nursing action is required before plugging the tube?  Deflate the cuff on the tube. 990) A client is diagnosed with glaucoma. Which piece of nursing assessment data identifies a risk factor associated with this eye disorder?  Cardiovascular disease 991) A client with retinal detachment is admitted to the nursing unit in preparation for a repair procedure. Which prescription should the nurse anticipate?  Placing an eye patch over the client's affected eye 992) The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing?  Encouraging active range-of-motion exercises 993) The nurse is caring for a client who is at risk for suicide. What is the priority nursing action for this client?  Provide authority, action, and participation 994) A client with tuberculosis whose status is being monitored in an ambulatory care clinic asks the nurse when it is permissible to return to work. What factor should the nurse include when responding to the client?  Three sputum cultures are negative. 995) A client comes to the emergency department after an assault and is extremely agitated, trembling, and hyperventilating. What is the priority nursing action for this client?  Remain with the client until the anxiety decreases. 996) The nurse is caring for a client admitted to the hospital with a suspected diagnosis of acute appendicitis. Which laboratory result should the nurse expect to note if the client does have appendicitis?  Leukocytosis with a shift to the left 997) The nurse is developing a plan of care for a client who was experiencing anxiety after the loss of a job. The client is now verbalizing concerns regarding the ability to meet role expectations and financial obligations. What is the priority nursing problem for this client?  Lack of ability to cope effectively 998) The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action?  Document the findings. 999) After performing an initial abdominal assessment on a client with nausea and vomiting, the nurse should expect to note which finding?  Waves of loud gurgles auscultated in all 4 quadrants 1000) The health care provider prescribes erythromycin suspension 800 mg by mouth. After reconstitution, how many milliliters should the nurse pour into the medicine cup to deliver the prescribed dose? Refer to figure. Fill in the blank. Figure from Brown, Mulholland (2012). View Figure  Correct Answer: 20 mL 1001) The nurse is monitoring a client with acute pericarditis for signs of cardiac tamponade. Which assessment finding indicates the presence of this complication?  Muffled or distant heart sounds 1002) The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction?  "I need to be sure that I elevate my leg above the level of my heart for at least an hour every day." 1003) The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to be avoided. The nurse instructs the client to avoid consuming which item?  Antacids 1004) The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse should plan to provide which instruction to the client?