Exam (elaborations) TEST BANK NCLEX Saunders Comprehensive Review for NCLEX-PN, ISBN: 9780721677941

Exam (elaborations) TEST BANK NCLEX Saunders Comprehensive Review for NCLEX-PN, ISBN: 7941 Ref # 4366 The nurse receives a client from the post anesthesia care unit following a left femoral-popliteal bypass graft procedure. Which of the following assessments requires immediate notification of the health care provider?  Left foot is cool to the touch  Absent left pedal pulse using Doppler analysis  Inability to palpate the left pedal pulse  Acute pain in the left lower leg Although the inability to palpate the left pedal pulse, a cool extremity, and increased pain in the left lower leg are important findings, they all require additional nursing assessment prior to contacting the health care provider. In clients without palpable pedal pulses, the next step in the assessment is to perform a Doppler analysis. The inability to locate the left pedal pulse using the Doppler analysis requires immediately notifying the health care provider. Ref # 1028 There's a new medication order that reads: "administer 1 gtt ciprofloxacin solution OD Q 4 h" What action should the nurse take? Call the prescriber to clarify and rewrite the order Abbreviations, symbols and dose designations can be misinterpreted and lead to medication errors. "OD" can mean "right eye" (oculus dexter) or "once daily"; it should never be used when communicating medical information. The abbreviation "Q" should be written out as "every." Although "gtt" is not on the official "Do Not Use List", it's best to use "drop" instead. Asking other nurses to interpret an order is a potentially dangerous "workaround." The nurse should call the health care provider who prescribed the medication and clarify the order. Ref # 1440 Which individual is at greatest risk for the development of hypertension? 45 year-old African-American attorney The incidence of hypertension is greater among African-Americans than other groups in the United States. The incidence among the Hispanic population is rising. Ref # 2446 A woman, who delivered five days ago and who had been diagnosed with pregnancy induced hypertension (PIH), calls a hospital triage nurse hotline to ask for advice. She states, "I have had the worst headache for the past two days. It pounds and by the middle of the afternoon everything I look at looks wavy. Nothing I have taken helps." What should the nurse do next? Ask the client to stay on the line, get the address, and send an ambulance to the home The woman is at risk for seizure activity. The ambulance needs to bring the woman to the hospital for evaluation and treatment. For at-risk clients, PIH may progress to preeclampsia and eclampsia prior to, during, or after delivery; this may occur up to 10 days after delivery. Ref # 2065 A client expresses anger when a call light is not answered within five minutes. The client demanded a blanket. How should the nurse respond? "I see this is frustrating for you. I have a few minutes so let's talk." This is the best response because it gives credence to the client's feelings and then concerns. To say "let's talk" and ask a why question is not a therapeutic approach because it does not acknowledge or validate the client's feelings. To apologize and not notice the client's feelings is inappropriate. To say it could have waited a few minutes is rude and non-accepting of the client's verbalized needs. Ref # 2134 The client is admitted to an ambulatory surgery center and undergoes a right inguinal orchiectomy. Which option is the priority before the client can be discharged to home Post-operative pain is managed An orchiectomy is the surgical removal of one or both testicles. It is usually performed to treat cancer (testicular, prostate or cancer of the male breast), but it may also be performed to prevent cancer (with an undescended testicle.) Due to the location of the incision, pain management is the priority. Most men will be able to eat regularly when they get home; they should at least tolerate liquids before discharge. It's important that the client is able to get up and walk with assistance, but this is not the priority. Psychological counseling may be needed as part of long-term aftercare, but this is not an immediate priority. Ref # 1524 A nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first? Smoking cessation Smoking cessation is the priority for clients at risk for cardiac disease. Smoking's effects result in reduction of cell oxygenation and constriction of the blood vessels. All of the other factors should be addressed at some point in time. Ref # 1721 The clinic nurse is assisting with medical billing. The nurse uses the DRG (Diagnosis Related Group) manual for which purpose? Determine reimbursement for a medical diagnosis DRGs are the basis of prospective payment plans for reimbursement for Medicare clients. Other insurance companies often use it as a standard for determining payment. KEYWORDS DRG diagnosis related group reimbursement Ref # 1328 A nurse is planning care for a 2 year-old hospitalized child. Which issue will produce the most stress at this age? Separation anxiety While a toddler will experience all of the stresses, separation from parents is the major stressor. Separation anxiety peaks in the toddler years. Ref # 2319 The nurse is reviewing the laboratory results for several clients. Which of the laboratory result indicates a client with partly compensated metabolic acidosis? PaCO2 30 mm Hg Metabolic acidosis can be caused by many conditions, including renal failure, shock, severe diarrhea, dehydration, diabetic acidosis, and salicylate poisoning. With metabolic acidosis, you should expect a low pH (less than 7.35) and a low HCO3 (less than 22 mEq/L.) Compensation means the body is trying to get the pH back in balance; therefore, a pure metabolic acidosis should elicit a compensatory decrease in PaCO3 (normal is 35-45 mm Hg.) The hemoglobin is within normal limits (WNL) for both males and females. The chloride and sodium results are also WNL. Ref # 2391 A client with a diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is appropriate to use when performing postmortem care? Contact precautionsThe resistant bacteria remain alive for up to three days after the client dies. Therefore, contact precautions must still be used. The body should also be labeled as MRSA-contaminated so that the funeral home staff can protect themselves as well. Gown and gloves are required. Ref # 1436 A client has a chest tube inserted immediately after surgery for a left lower lobectomy. During the repositioning of the client during the first postop check, the nurse notices 75 mL of a dark, red fluid flowing into the collection chamber of the chest drain system. What is the appropriate nursing action? Continue to monitor the rate of drainage It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position this soon after surgery. The dark color of the blood indicates it is not active bleeding inside of the chest. Sanguinous drainage should be expected within the initial 24 hours postop, progressing to serosanguinous and then to a serous type. If the drainage exceeds 100 mL/hr, the nurse should call the surgeon. Ref # 1623 A client is transported to the emergency department after a motor vehicle accident. When assessing the client 30 minutes after admission, the nurse notes several physical changes. Which finding would require the nurse's immediate attention? Tracheal deviation Tracheal deviation is a sign that a mediastinal shift has occurred, most likely due to a tension pneumothorax. Air escaping from the injured lung into the pleural cavity causes pressure to build, collapsing the lung and shifting the mediastinum to the opposite side. This obstructs venous return to the heart, leading to circulatory instability and may result in cardiac arrest. This is a medical emergency, requiring emergency placement of a chest tube to remove air from the pleural cavity relieving the pressure. Ref # 1319 The client is diagnosed with cystic fibrosis (CF). The nurse would expect the client to be treated with oral pancreatic enzymes and which type of diet? High fat, high-calorie CF affects the cells that produce mucus, sweat and digestive juices. Someone with CF needs a high-energy diet that includes high-fat and high-calorie foods, extra fiber to prevent intestinal blockage and extra salt (especially during hot weather.) People with CF are at risk for osteoporosis and need calcium and dairy products. Someone with celiac disease or with a gluten intolerance, not CF, needs a gluten-free diet. Ref # 1646 The nurse is assessing a 4 year-old child who is in skeletal traction 24 hours after surgical repair of a fractured femur. The child is crying and reports having severe pain. The right foot is pale and there is no palpable pulse. What action should the nurse take first? Notify the health care provider Pain and absence of a pulse within 48-72 hours after a severe injury to an extremity suggests acute compartment syndrome. This condition occurs when there's a build up of pressure within the muscles; this pressure decreases blood flow and can cause muscle and nerve damage. Acute compartment syndrome is a medical emergency. Surgery is needed immediately; delaying surgery can lead to permanent damage to the extremity. Ref # 1927 The nurse is examining a 2 year-old child with a tentative diagnosis of Wilm's tumor. The nurse would be most concerned about which statement by the mother? "Urinary output seems to be less over the past two days." Wilm's tumor is a malignant tumor of the kidney that can lead to kidney dysfunction; therefore, a recent decrease in urinary output should be investigated further as it may be a sign of renal dysfunction. Increasing abdominal girth is a common finding in Wilm's tumor, but does not require immediate intervention by the nurse. Ref # 1370 A child is treated with succimer for lead poisoning. Which of these assessments should the nurse perform first? Check complete blood count (CBC) with differential Succimer (Chemet) is used in the management of lead or other heavy metal poisoning. Although it has generally well tolerated and has a relatively low toxicity, it may cause neutropenia. Therapy should be withheld or discontinued if the absolute neutrophil count (ANC) is below 1200/µ Ref # 1773The client with a T-2 spinal cord injury reports having a "pounding" headache. Further assessment by the nurse reveals excessive sweating, rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. What action should the nurse take next? Check the client for bladder distention and the urinary catheter for kinks These are findings of autonomic dysreflexia, also called hyperreflexia. This response occurs in clients with a spinal cord injury above the T-6 level. It is typically initiated by any noxious stimulus below the level of injury such as a full bladder, an enema or bowel movement, fecal impaction, uterine contractions, changing of the catheter and vaginal or rectal examinations. The stimulus creates an exaggerated response of the sympathetic nervous system and can be a lifethreatening event. The BP is typically extremely high. The priority action of the nurse is to identify and relieve the cause of the stimulus. Ref # 2144 A 67 year-old client is admitted with substernal chest pressure that radiates to the jaw. The admitting diagnosis is acute myocardial infarction (MI). What should be the priority nursing diagnosis for this client during the first 24 hours? Altered tissue perfusion In the immediate post MI period, altered tissue perfusion is priority, as an area of myocardial tissue has been damaged by a lack of blood flow and oxygenation. Interventions should be directed toward promoting tissue perfusion and oxygenation. The other problems are also relevant, but tissue perfusion is the priority. Ref # 1740An external disaster has occurred in the town. The triage nurse from the emergency department is transported to the site and assigned to triage the injured. Which of these clients would the nurse tag as "to be seen last" by the providers at the scene? A middle-aged person with deep abrasions that are over 90% of the body The clients that are least likely to survive are to be tagged as the "last to be seen." Deep abrasions are usually treated as second or third degree burns because the fluid loss is great. ref # 1750The nurse is caring for a client who is in the advanced stage of multiple myeloma. Which action should be included in the plan of care? Careful repositioning Multiple myeloma occurs when abnormal plasma cells (myeloma cells) collect in several bones. This disease may also harm other tissues and organs, especially the kidneys. This type of cancer causes hypercalcemia, renal failure, anemia,and bone damage. Because multiple myeloma can cause erosion of bone mass and fractures, extra care should be taken when moving or positioning a client due to the risk of pathological fractures. Ref # 2332 The nurse is teaching the client with chronic renal failure (CRF) about medications. The client questions the purpose of taking aluminum hydroxide. What is the best explanation for the nurse to give the client about the therapeutic effects of this medication? It decreases serum phosphate Aluminum binds phosphates that tend to accumulate in the client with chronic renal failure due to decreased filtration capacity of the kidney. Antacids such as Amphojel are commonly used to decrease serum phosphate. Ref # 1771The nurse is caring for a client in the late stages of amyotrophic lateral sclerosis (ALS). Which finding would the nurse expect? (Stephen hawkins) Shallow respirations ALS is a chronic progressive neurodegenerative disease that affects nerve cells in the brain and spinal cord. In ALS, upper and lower motor neurons degenerate (die) and stop sending messages to muscles; all muscles under voluntary control eventually weaken and atrophy. People eventually lose their ability to speak, eat, move and breathe. However, ALS does not impair a person's mind or intelligence. ALS does not affect a person's ability to see, smell, taste, hear or recognize touch. Ref # 1625 A nurse is caring for a client two hours after a right lower lobectomy. During the assessment of the chest drainage unit (CDU), the nurse notes bubbling in the water-seal chamber. What is the first action the nurse should take? Assess the chest tube dressing, tubing and drainage system The first action the nurse should take is to thoroughly check the dressing, tubing and drainage system. Usually intermittent bubbling in the water-seal chamber right after surgery indicates an air leak from the pleural space; this is a common finding and should resolve as the lung re-expands. Continuous bubbling usually means a leak in the CDU, such as a loose connection or a leak around the insertion site. Other nursing actions will include assessing the color and amount of the drainage and assessing the lungs. After the initial post-operative period, the nurse will assist the client to change positions and cough and deep breath to help re-expand the lung and promote fluid drainage. Ref # 1551Today's prothrombin time for a client receiving warfarin 20 seconds. The normal range listed by the lab is 10 to 14 seconds. What is an appropriate nursing action? Recognize that this is a therapeutic level For the client on warfarin therapy, this prothrombin level is within the therapeutic range. Therapeutic levels for warfarin are usually 1 1/2 to 2 times the normal levels. Ref # 1599 The nurse is teaching a client with coronary artery disease about nutrition. What information should the nurse be sure to emphasize Avoid large and heavy meals Eating large, heavy meals can pull blood away from the heart for the digestion process. This may result in angina for clients with coronary artery disease. Sodium for clients with cardiac disease is limited to two grams per day. Three meals a day is a correct approach. However, it does not mention the size of the meal, which is more important. Ref # 1749 The client, who is receiving chemotherapy through a central venous access device (CVAD) at home, is admitted to the intensive care unity (ICU) with a diagnosis of sepsis. Which of the following nursing interventions is the priority? Prepare the client for insertion of a new CVAD Many cases of sepsis occur in immunocompromised clients and clients with chronic and debilitating diseases. Since it's likely the existing CVAD is the source of the infection, it should be cultured and removed. A new central line (usually an internal jugular or subclavian) needs to be inserted since large amounts of IV fluids are needed to restore perfusion. The new central line will also allow venous access for labs, medications and measuring central venous pressure. Together with central venous pressure monitoring, an indwelling urinary catheter will help guide fluid volume replacement. Many hospitals have restrictions on visitors with known or recent infections to help protect all clients. Ref # 1525 The client is scheduled for coronary artery bypass. Based on principles of teaching and learning, what is the best initial approach by the nurse during pre-op teaching? Assess the client's learning style As with any anticipatory teaching, assessment of the client's level of knowledge and learning style should occur first. If possible, the three senses of hearing, seeing and touching should be used during any teaching to enhance recall Ref # 1246 During assessment of orthostatic vital signs on a client with cardiomyopathy, the nurse finds that the systolic blood pressure (BP) decreased from 145 to 110 mm Hg between the supine and upright positions while the heart rate (HR) rose from 72 to 96 beats per minute. In addition, the client reports feeling lightheaded when standing up. The nurse should implement which of the following actions? Instruct client to increase fluid intake for several hours This client is experiencing postural hypotension, a decrease in systolic blood pressure 15 mm Hg accompanied by an increase in heart rate 15 to 20 beats above the baseline with a change in position from supine to upright. This is often accompanied by lightheadedness. Fluid replacement is appropriate, but must be instituted very cautiously, as this client with cardiomyopathy will also be very sensitive to changes in fluid status and fluid overload may develop rapidly with aggressive rehydration. After the client increases fluid intake for one to two hours, the client should be reassessed for resolution of the postural hypotension. Ref # 1595 The nurse is caring for a client diagnosed with acute angina. The client is receiving an intravenous infusion of nitroglycerin. What is the priority assessment during this treatment? Blood pressure the vasodilatation that occurs as a result of this medication can cause profound hypotension. The client's blood pressure must be evaluated every 15 minutes until stable, and then every 30 minutes to every hour thereafter. Clients receiving IV nitroglycerin also require continuous ECG monitoring. Ref # 2159 A client, admitted to the unit because of severe depression and suicidal threats, is placed on suicidal precautions. The nurse should be aware that the danger of the client committing suicide is greatest at what period of time? When the client's mood improves with an increase in energy level Suicide potential is often increased when there is an improvement in mood and energy level. At this time ambivalence is often decreased and a decision is made to commit suicide. The clients have the energy to carry through with the plan for suicide. Ref # 1815 A mother asks about expected motor skill development for her 3 yearold child. Which activity is considered a typical motor skill for the 3 year-old? Riding a tricycle Three year-old children are developing gross motor skills that require large muscle movement. While there will always be some variation between children, movement milestones typically include pedaling a tricycle, standing on one foot for a few seconds, walking backwards and jumping with both feet. The other activities listed require more coordination and are movement milestones for older children Ref # 1539 The nurse needs to accurately assess gastric placement of a nasogastric tube prior to the administration of an enteral feeding. What is the priority action the nurse should take before starting the infusion? Check the pH of the aspirate Once the initial placement of the tube has been confirmed by x-ray, the nurse will check the pH of the aspirate before administering medications or enteral feeding solutions. Current practice recommendations include assessing the feeding tube placement by testing the pH of aspirates, measuring the external portion of the tube, and observing for changes in the volume and appearance of feeding tube aspirates. If tube placement is in doubt, an x-ray should be obtained. The other methods are older approaches that are no longer recommended. Ref # 2339 There is an order to administer intravenous gentamicin three times a day. What diagnostic finding indicates the client may be more likely to experience a toxic side effect of this medication? High serum creatinine Gentamicin is excreted unmodified by the kidneys. If there is any reduced renal function, toxicity can result. An elevated serum creatinine indicates reduced renal function and this puts the client at greater risk for toxicity. Reduced renal function will delay the excretion of many medications. Ref # 1582 A nurse is working in an OB-GYN clinic. A 40 year-old woman in the first trimester of an unplanned pregnancy provides a health history to the nurse. Which information should receive priority attention? She has been taking an ACE inhibitor for her blood pressure for the past two years. A report by the client that she has been taking medications in the first trimester of pregnancy should be followed up immediately. ACE inhibitors, commonly used to control high blood pressure, are pregnancy category X, as they can cause teratogenic effects on the developing fetus, increasing the risk of birth defects. Women who are taking medications and who are planning a pregnancy should be switched to medications that are not harmful to the developing fetus before they begin trying to get pregnant. Ref # 2266 The nurse is providing information to a client about a prescribed medication. Which one of these statements, if made by a client, indicates that teaching about propranolol (Inderal) has been effective? "I can have a heart attack if I stop this medication suddenly." Propranolol is commonly used to treat hypertension, abnormal heart rhythms, heart disease and certain types of tremor. It is in a class of medications called beta blockers. Suddenly discontinuing a beta blocker can cause angina, hypertension, arrhythmias, or even a heart attack. Ref # 1644 The nurse is developing a teaching plan for parents on safety and riskreduction in the home. Which of the following should the nurse give priority consideration to during teaching? Age of children in the home Age and developmental level of the child are the most important considerations in the provision of a framework for anticipatory guidance associated with safety, and should be given priority when teaching safety. Ref # 1312 The client is prescribed dexamethasone by mouth every other day and asks the nurse for more information about the medication. What information would the nurse want to share with the client? (Select all that apply) Take the medication with food Do not get any immunizations or skin tests Mark your calendar to keep track of doses Dexamethasone is a glucocorticosteroid used for its anti-inflammatory properties. It is best to take the medication in the morning, before 9:00 am, with food or milk to avoid stomach upset. A low-sodium diet is usually prescribed because the drug can cause an elevation in blood pressure, salt and water retention, and increased potassium loss. Dexamethasone also causes calcium loss; the client should increase calcium in the diet and take a calcium supplement. Because the medication affects the immune system, it could make vaccinations ineffective and/or lead to serious infections. It's always a good idea for clients to keep track of medication administration, particularly when they are not taking the medication every day. Ref # 2419 A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) four hours ago. At the time of rupture, maternal vital signs were within normal limits, she was dilated to 2 centimeters, and the baseline fetal heart rate (FHR) was 150 beats per minute (BPM). The nurse is now reassessing the client. Which of these assessment findings may be an early indication that the client is developing a complication of the labor process? Fetal heart rate is 188 beats/minute Prolonged ruptured membranes may lead to maternal infection (as suggested by the slightly elevated temperature). But the primary concern is the fetal heart rate of 188; fetal heart rate is typically somewhere between 120 and 160 BPM. Fetal tachycardia may be an early sign of hypoxia. The nurse should contact the health care provider, assist the client to change positions, and administer oxygen and intravenous fluids. Ref # 2247 The registered nurse (RN) is planning the care of an 80-year-old client with skin abrasions from a fall in the home. What aspect of this client's care is the primary responsibility of the nurse? Perform a head-to-toe assessment The RN is responsible to conduct a thorough assessment and evaluation of all body systems for this client. The nurse would document information collected during the focused assessment, such as changes in skin color and breaks in the skin's integrity. Applying lotion would not be a primary responsibility. Ref # 1650 A 15 year-old client has been placed in a Milwaukee brace. Which statement made by the client is incorrect and indicates a need for additional teaching? "I will only have to wear this for six months." The brace must be worn long-term, during periods of growth, usually for one to two years. It is used to correct scoliosis, the lateral curvature of the spine. Ref # 1629 The nurse, who is participating in a community health fair, assesses the health status of attendees. When would the nurse conduct a mental status examination? As part of every health assessment A mental status assessment is a critical part of baseline information and should be a part of every examination. Ref # 1520 A nurse is talking by telephone with a parent of a 4 year-old child who has chickenpox. Which approach demonstrates appropriate teaching by the nurse? Papules, vesicles and crusts will be present at one time All three stages of the chickenpox lesions will be present on the child's body at the same time. Children should not be medicated with aspirin due the possibility of developing Reye's syndrome. A person with chickenpox is contagious one to two days before their blisters appear and remain contagious until all the blisters have crusted over. Antiviral medications are not usually prescribed to otherwise healthy children. Over-the-counter hydrocortisone creams can help relieve itchy skin Ref # 5280 During a yearly health screening, a 54 year-old female reports having irregular menstrual cycles, mood swings and hot flashes. She requests a more natural approach to manage these symptoms of perimenopause. What education about non-pharmacological interventions will the nurse include in client teaching? (Select all that apply.) "You should drink at least 8-10 glasses of water a day." "Yoga may help you manage stress and relieve symptoms." "Incorporate more vegetables and legumes in your diet." "Use deep breathing exercises when you start having a hot flash." Measures that have been found to be effective in helping manage symptom of hot flashes include exercise, stress reduction and getting enough sleep at night. Reducing the temperature in the room at night and taking a warm bath or shower before bedtime can help clients get a better night's sleep. Slow abdominal breathing (6-8 breaths a minute) at the onset of hot flashes can help. Other measures that can lessen the number of and severity of hot flashes include yoga, as well as avoiding alcohol, spicy foods and caffeine. Eating a more plant-based diet can also help. Ref # 1776 A nurse uses the New Ballard Scale to assess gestational age of a newborn. The assessment score total is very high. What is a reasonable interpretation of this result? The baby is post-term Birth weight and gestational age are important indicators of the newborn's health and are used to identify any (potential) problems. The New Ballard Scale can help differentiate, for example, between a small for gestational age baby and one that is premature. The New Ballard Scale scoring system adds up the individual scores for 6 external physical assessments and 6 neuromuscular assessments; the total score may range from -10 to 50. Premature babies have lower scores; higher scores correlate with post-maturity. Fetal distress during labor can result in lower scores. Ref # 5307 A new task force has been created at a hospital to address a recent increase in patient falls. The first meeting is scheduled with members from several departments. Which of the following statements by the nurse leader indicate intent to increase meeting effectiveness? (Select all that apply.) "During our meeting today we will share the information we have on falls." "Let's discuss when next we should meet and what information we will bring." "Please introduce yourselves and your departments." "Let's focus on the number of falls first and then we can talk about staffing." A leader increases meeting effectiveness by not permitting one person not to dominate the discussion, encouraging brainstorming, encouraging others to further develop ideas and helping to engage the team in future discussions. An effective team leader will periodically summarize the information and ensure that all ideas are recorded for all to see (for example, on a whiteboard) and then follow up with minutes of the meeting. Beginning and ending on time is also important to keep everyone focused on the task at hand and to demonstrate respect team members' other commitments. Ref # 1728 A nurse is reviewing laboratory results on a client diagnosed with acute renal failure. Which lab result should be reported immediately? Serum potassium 6 mEq/L (6 mmol/L) Although all of these findings are abnormal, the elevated potassium level 3.5 to 5.0 is a life-threatening finding and must be reported immediately. Serious consequences of hyperkalemia include heart block, asystole and life-threatening ventricular dysrhythmias. Anemia (hemoglobin less than 13 g/dL [130 g/L] in men or less than 12 mg/dL [120 g/L] in women