Saunders Comprehensive Review For Nclex 5 - 2020 | Saunders Comprehensive Review For Nclex

SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FIVE 1000+ Questions and answers 1) A child with an autism spectrum disorder (ASD) is being admitted to the hospital for diagnostic tests. Which room assignment is the most appropriate for the child?  Private room 2) The labor and delivery room nurse has just received reports on 4 clients. After reviewing the client data, the nurse should assess which client first?  A client who has just received an intravenous loading dose of magnesium sulfate to stop preterm labor 3) The nurse has developed a teaching plan for a client with hypertension regarding the administration of prescribed medications. What is the initial nursing action?  Assess the client's readiness to learn. 4) A client with cancer is receiving intravenous morphine sulfate for pain. When writing the plan of care for this client, the nurse should include which action as the priority action?  Monitor respiratory status. 5) The nurse is preparing to suction the airway of a client who has a tracheostomy tube and gathers the supplies needed for the procedure. In order of priority, which actions should the nurse take to perform this procedure? Arrange the actions in the order that they should be performed. All options must be used.  1) Place the client in a semi Fowler's position.  2) Turn on the suction device and set the regulator at 80 mm Hg.  3) Attach the suction tubing to the suction catheter.  4) Hyperoxygenate the client.  5) Insert the catheter into the tracheostomy until resistance is met, and then pull it back 1 cm.  6) Apply intermittent suction and slowly withdraw the catheter while rotating it back and forth. 6) The nurse notes blanching, coolness, and edema at a client's peripheral intravenous (IV) site. Which nursing action is the priority?  Remove the IV catheter. 7) A client has a prescription to begin an infusion of 1000 mL of 5% dextrose in lactated Ringer's solution. The client has an intravenous (IV) cannula inserted, and the nurse prepares the solution and IV tubing. Arrange the actions in the order that they should be performed. All options must be used.  1) Close the roller clamp on the IV tubing.  2) Spike the IV bag and half-fill the drip chamber.  3) Open the roller clamp and fill the tubing.  4) Uncap the distal end of the tubing.  5) Attach the distal end of the tubing to the client. 8) The nurse is caring for 4 pediatric clients. After receiving reports from the night shift, which child should the nurse assess first?  A 6-week-old infant admitted to the hospital for decreased level of consciousness; shaken baby syndrome is suspected 9) The nurse is assigned to 4 clients on a postoperative surgical unit at a rural hospital. When prioritizing the care, the nurse recognizes that the highest priority is focused on which client?  The client with problems clearing the airway related to abdominal incision pain 10) The emergency department nurse is caring for a child with suspected epiglottitis and has ensured that the child has a patent airway. Which action is the next priority in the care of this child?  Prepare the child for a chest radiograph. 11) The nursing instructor asks the nursing student to identify the priorities of care for an assigned client. The nursing instructor determines that the nursing student understands the client's needs when which statement is made?  "Actual or life-threatening concerns are the priority." 12) A hospitalized client with type 1 diabetes mellitus received Humulin N and Humulin R insulin 2 hours ago (at 7:30 a.m.). The client calls the nurse and reports that he is feeling hungry, shaky, and weak. The client ate breakfast at 8 a.m. and is due to eat lunch at noon. Arrange the actions that the nurse will take in the order that they should be performed. All options must be used.  1) Check the client's blood glucose level.  2) Give the client ½ cup (118 mL) of fruit juice to drink.  3) Take the client's vital signs.  4) Retest the blood glucose level.  5) Give the client a small snack of carbohydrate and protein.  6) Document the client's complaints, actions taken, and outcome. 13) An emergency department nurse is preparing to receive 4 clients as a result of a motor vehicle crash. Which victim should the nurse attend to first?  A 45-year-old man with chest pain, shortness of breath, and diaphoresis 14) The nurse is assigned to care for 4 clients. Which client should the nurse assess first?  A client who has a peripheral (index finger) oxygen saturation percentage of 85% 15) The nurse has received her client assignment for the day. Which client should the nurse care for first?  A client with postoperative pain reported at 7 out of 10, with 10 being the worst 16) The nurse has received the client assignment for the day. Which client should the nurse care for first?  The client admitted with the medical diagnosis of neutropenia who is afebrile and is complaining of pain with urination 17) The nurse is the first responder at the scene of a 6-car crash on a highway. Which victim should the nurse attend to first?  A victim experiencing dyspnea 18) The nurse in charge of a nursing unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply.  A client with a Holter monitor  A client receiving oral antibiotics  A client experiencing sinus rhythm 19) The nurse has received her client assignment for the day. Which client should the nurse check first?  A client who has just returned from surgery 20) The nurse is a responder at the scene of a building collapse. Which victim should the nurse care for first?  Victim with an apparent chest wall defect and asymmetrical chest wall movement 21) The nurse manager of a medical-surgical unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply.  Client postoperative day 1 after inguinal herniorrhaphy, vital signs stable  Client 5 days after a myocardial infarction, vital signs stable, absence of dysrhythmias  Client 1 day after cardiac catheterization, normal study results, groin site free of hematoma 22) The nurse is the first responder at the scene of an accident in which a tire blowout caused a bus to roll over several times. Which victim should the nurse attend to first?  The confused 12-year-old with bright red blood pulsing from an open fracture of the femur 23) The nurse in charge of a nursing unit is asked to select those hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply.  The client who 24 hours earlier gave birth to her second child by caesarean delivery  The 48-hour postoperative client who has undergone an ileostomy because of ulcerative colitis  The 2-day postoperative client who has undergone total knee replacement and is ambulating with a walker  The 3-day postoperative client who has undergone coronary artery bypass grafting and is ready for rehabilitation 24) The nurse has received her client assignment for the day. Which client should the nurse care for first?  The 53-year-old client with heart failure who has gained 4 pounds (1.8 kg) since yesterday and is short of breath 25) During morning report, the day nurse is given information on the assigned clients. Which client should the nurse assess first?  The 60-year-old client with leukemia who is receiving the first round of chemotherapy, which was started at 0630 and is scheduled to end at noon 26) The nurse determines that which client has the highest priority needs?  The client who has an irregular apical pulse of 120 beats per minute 27) When planning care, which client should the nurse assess first?  The client with a chest tube for a pneumothorax 28) The nurse assigned to 4 clients reviews client data at the beginning of the shift. To which information should the nurse give highest priority?  Pulse oximetry reading 89% - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 970) The nurse is providing instructions to the mother of a child who has been exposed to human immunodeficiency virus infection. The nurse should include notifying the health care provider if which symptom occurs in the child?  Coughing 971) A 3-year-old child with human immunodeficiency virus infection is being discharged from the hospital. The nurse is providing discharge instructions to the mother regarding home care and infection control measures. Which statement by the mother indicates a need for further teaching?  "I should discard any unused food and formula immediately." 972) The nurse is providing instructions to the mother of a child with human immunodeficiency virus infection regarding immunizations. Which statement by the mother indicates an understanding of the immunization schedule?  "Family members in the household need to receive the influenza vaccine." 973) A child was seen in the health care clinic and received an immunization of DPT (diphtheria, pertussis, tetanus) vaccine. One hour later, the mother calls the clinic and tells the nurse that the injection site is painful and red. Which instruction should the nurse provide to the mother?  Apply cold compresses for 24 hours for 20 minutes at a time 974) The nurse is preparing to administer an MMR (measles, mumps, and rubella) vaccine to a 15-month-old child. Before administering the vaccine, which question should the nurse ask the mother of the child?  "Is the child allergic to any antibiotics?" 975) The nurse is caring for a child with a diagnosis of neutropenia. Which nursing interventions are most appropriate for a child placed in protective isolation for neutropenia? Select all that apply.  Place the child on a low-bacteria diet.  Change dressings using sterile technique.  Peel fruits and vegetables before allowing the child to eat them 976) The mother of a preschooler who attends day care calls a clinic nurse and tells the nurse that the child is constantly scratching the perianal area and that the area is irritated. The nurse suspects the possibility of pinworm infection (enterobiasis) and instructs the mother to obtain a rectal specimen by a tape test. At what time should the nurse tell the mother to obtain the specimen?  In the morning, when the child awakens 977) Several children have contracted rubeola (measles) in a local school, and the school nurse conducts a teaching session for the parents of the schoolchildren. Which statement made by a parent indicates a need for further teaching regarding this communicable disease?  "The disease can be spread to others from 10 days before any sign of the disease appears to 15 days after the rash appears." 978) The nurse provides instructions to the mother of a child with mumps regarding respiratory precautions, and the mother asks the nurse about the length of time required for the respiratory precautions. The nurse should make which statement to the mother?  "Precautions are indicated during the period of communicability." 979) A mother brings her 6-year-old child to the clinic because the child has developed a rash on the trunk and scalp. The mother reports that the child has had a low-grade fever, has not felt like eating, and has been tired. The child is diagnosed with chickenpox. The mother inquires about the communicable period associated with chickenpox, and the nurse bases the response on which statement?  The communicable period is 1 to 2 days before the onset of the rash to 6 days, when crusts have formed. 980) A child diagnosed with scarlet fever is being cared for at home. The home health nurse performs an assessment on the child and checks for which clinical manifestations of this disease? Select all that apply.  Pastia's sign  White strawberry tongue  Edematous and beefy-red pharynx 981) A child with acquired immunodeficiency syndrome is hospitalized for the treatment of Pneumocystis jiroveci pneumonia. The child will be receiving nebulizer treatments at home when discharged. The nurse instructs the mother regarding the maintenance of the nebulizer equipment. What should the nurse tell the mother to do?  Clean the nebulizer pieces with warm water after each treatment and allow to air dry. 982) A 12-month-old child with human immunodeficiency virus infection is currently immunocompromised. The nurse determines that the immunization needs of this child include which action?  Delaying the administration of the varicella virus vaccine until the child is not immunocompromised 983) The nursing student is assigned to administer immunizations to children in a clinic. The student should question whether to administer immunizations to a child with which condition?  A severe febrile illness 984) The nurse is providing anticipatory guidance to the mother of a 10-month-old child. The mother asks how soon her daughter will be able to receive the chickenpox (varicella) vaccine. What is the best nursing response?  "She can receive it when she is 12 months old." 985) A child is scheduled to receive immunizations. The child's mother reports to the nurse that the child has been receiving long-term immunosuppressive therapy. The nurse prepares the scheduled immunizations knowing that which vaccine is contraindicated?  MMR (measles-mumps-rubella) 986) A child is sent to the school nurse by the teacher. On assessment of the child the nurse notes the presence of a rash. The nurse suspects that the child has erythema infectiosum (fifth disease) based on which assessment finding?  Erythema on the face, giving a "slapped cheeks" appearance 987) An infant is brought to the clinic for his third diphtheria–tetanus toxoid–acellular pertussis vaccination (DTaP). The mother reports that the infant developed a 99.4°F (37.4°C) temperature after the last DTaP. Which action is most appropriate?  Administer the vaccination. 988) The nurse should expect to administer the first dose of the measles, mumps, and rubella (MMR) vaccine at which age?  12 months 989) A school-age child is seen in the health care provider's office for complaints of intense itching mostly at night. The health care provider makes a diagnosis of scabies and prescribes permethrin for treatment of the skin condition. Which at-home instruction should the nurse provide to the mother?  Apply the lotion liberally to the body and head, avoiding the eyes and mouth. 990) A child who is 4 years old is seen for a well-child checkup. He has been regularly receiving immunizations. Which immunizations should the child receive at this visit? Select all that apply.  Varicella vaccine  Inactivated polio vaccine  Measles, mumps, rubella (MMR) vaccine 991) 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?  Keep the child in a room with dim lights. 992) A child is seen in the health care clinic, and the nurse suspects the presence of pinworm infection (enterobiasis). The nurse instructs the mother as to how to obtain a cellophane tape rectal specimen. Which statement by the mother indicates an understanding of the correct procedure to obtain the specimen?  "I need to place a piece of transparent cellophane tape lightly over the anal area as soon as my child awakens and bring it to the clinic for examination." 993) An adolescent is seen in the health care clinic with complaints of chronic fatigue. On physical examination, the nurse notes swollen lymph nodes, and laboratory test results indicate the presence of Epstein-Barr virus (mononucleosis). The nurse provides instruction regarding care of the adolescent. Which statement made by the mother indicates an understanding of the care measures?  "I will call the doctor if my child has abdominal or left shoulder pain." 994) The nurse is caring for a hospitalized child with a diagnosis of measles (rubeola). In preparing to care for the child, which supplies should the nurse bring to the child's room to prevent transmission of the virus?  Mask and gloves 995) The nurse is caring for a child with a diagnosis of roseola. The nurse provides instructions to the mother regarding prevention of the transmission to siblings and other household members. Which instruction should the nurse provide?  Avoid allowing the children to share drinking glasses or eating utensils because the disease is transmitted through saliva. 996) A child hospitalized with pertussis is in the convalescent stage, and the nurse is preparing the child for discharge. The nurse has provided instructions to the parents for home care of the child. Which statement by a parent indicates a need for further teaching?  "I need to make sure that the child is isolated from the other children for at least 2 weeks to prevent the spread of the virus to them." 997) A child is seen in a health care clinic, and a diagnosis of chickenpox is confirmed. The mother expresses concern for two other children at home and asks the nurse if the child is infectious to the other children. Which response by the nurse is most appropriate?  "The infectious period begins 1 to 2 days before the onset of the rash and ends about 5 days after the onset of the lesions and crusting of the lesions." 998) The nurse is developing a plan of care for a 10-year-old girl with an exacerbation of eczema. Which problem should be addressed in the care for this child?  The client is at risk for infection related to scratching of pruritic lesions. 999) The nurse is providing a yearly summer educational session to parents in a local community. The topic of the session is prevention and treatment measures for poison ivy. The nurse instructs the parents that if the child comes into contact with poison ivy to take which action?  Shower the child immediately, lathering and rinsing the exposed skin several times. 1000) A 2-year-old child is admitted to a hospital burn unit with partial- and full-thickness burns involving 35% of body surface area. After admission assessment and review of the health care provider's prescriptions, the priority nursing intervention should focus on which action?  Inserting an indwelling urinary catheter