Marty's Saunders NCLEX-RN Remediation Questions And Answers 2023 A+

Marty's Saunders NCLEX-RN Remediation Questions And Answers 2023 A+ The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this method, which questions would the nurse ask the client? Select all that apply. "Where is the pain located?" "Does pain medication help?" "What does the pain feel like?" "How does the pain affect you?" "Do you have the pain when you sleep?" "What makes your pain better or worse?" - Correct Answer-"Where is the pain located?" "What does the pain feel like?" "How does the pain affect you?" "What makes your pain better or worse?" Rationale: The PQRSTU method is one method of assessing pain. With this method, the nurse asks about the following: Precipitating factors (option 6); Quality of the pain (option 3); Region or Radiation of the pain (option 1); Severity of the pain; Timing of the pain (continuous or intermittent); and How the pain affects yoU (option 4). Options 2 and 5 may be questions that would be asked; however, these are not a part of the PQRSTU method. A nurse is checking lochia discharge in a woman in the immediate postpartum period. The nurse notes that the lochia is bright red and contains some small clots. Based on this data, the nurse should make which interpretation? The client is hemorrhaging. The client needs to increase oral fluids. The client is experiencing normal lochia discharge. The client's health care provider needs to be notified of the finding. - Correct AnswerThe client is experiencing normal lochia discharge. Rationale: Lochia, the uterine discharge present after birth, initially is bright red and may contain small clots. During the first 2 hours after birth, the amount of uterine discharge should be approximately that of a heavy menstrual period. After that time, the lochial flow should steadily decrease, and the color of the discharge should change to a pinkish red or reddish brown. Because this is a normal, expected occurrence, options 1, 2, and 4 are incorrect. A nurse is assessing a woman in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which finding would the nurse expect to note if abruptio placentae is present? Soft uterus Abdominal pain Nontender uterus Painless vaginal bleeding - Correct Answer-Abdominal pain Rationale: Classic signs and symptoms of abruptio placentae include vaginal bleeding, abdominal pain, and uterine tenderness and contractions. Mild to severe uterine hypertonicity is present. Pains is mild to severe and either localized or diffuse over one region of the uterus, with a board-like abdomen. Painless vaginal bleeding and a soft, nontender uterus in the second or third trimester of pregnancy are signs of placenta previa. A nurse in the labor room is caring for a client who is in the first stage of labor. On assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Based on this finding, which is the appropriate nursing action? Contact the health care provider. Place the mother in a Trendelenburg position. Administer oxygen to the client by face mask. Document the findings and continue to monitor fetal patterns. - Correct AnswerDocument the findings and continue to monitor fetal patterns. Rationale: Early deceleration of the FHR refers to a gradual decrease in the heart rate, followed by a return to baseline, in response to compression of the fetal head. It is a normal and benign finding. Because early decelerations are considered benign, interventions are not necessary. Therefore, options 1, 2, and 3 are unnecessary. A woman in the third trimester of pregnancy with a diagnosis of mild preeclampsia is being monitored at home. The home care nurse teaches the woman about the signs that need to be reported to the health care provider. The nurse should tell the woman to call the health care provider if which occurs? Urine tests negative for protein. Fetal movements are more than four per hour. Weight increases by more than 1 pound in a week. The blood pressure reading is ranging between 122/80 and 132/88 mm Hg. - Correct Answer-Weight increases by more than 1 pound in a week. Rationale: The nurse would instruct the client to report any increase in blood pressure, protein in the urine, weight gain greater than 1 pound per week, or edema. The client also is taught how to count fetal movements and is instructed that decreased fetal activity (three or fewer movements per hour) may indicate fetal compromise and should be reported. A woman in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The woman tells the nurse that she frequently has leg cramps, primarily when she is reclining. Once thrombophlebitis has been ruled out, the nurse should tell the woman to implement which measure to alleviate the leg cramps? Apply heat to the affected area. Take acetaminophen (Tylenol) every 4 hours. Self-administer calcium carbonate tablets three times daily. Purchase a chewable antacid that contains calcium and take a tablet with each meal. - Correct Answer-Apply heat to the affected area. Rationale: Leg cramps may be a result of compression of the nerves supplying the legs by the enlarging uterus, a reduced level of diffusible serum calcium, or an increase in serum phosphorus. In the pregnant woman who complains of leg cramps, the nurse would perform further assessments to ensure that the client is not experiencing thrombophlebitis. Once this has been ruled out, the nurse would instruct the woman to place heat on the affected area, dorsiflex the foot until the spasm relaxes, or stand and walk. The health care provider may prescribe oral supplementation with calcium carbonate tablets or calcium hydroxide gel with each meal to increase the calcium level and lower the phosphorus level, but the nurse would not prescribe these or any other medications. A client who has been hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, "My roommate will steal me blind." Which is the appropriate response by the nurse? "Why do you believe this?" "Tell me more about the details of your belief." "I hear what you are saying, but I don't share your belief." "If you want a pass for tomorrow evening's movie, you'd better turn that light off this minute." - Correct Answer-"I hear what you are saying, but I don't share your belief." Rationale: Paranoid beliefs are coping mechanisms used by the client and therefore are not easily relinquished. It is important not to support the belief and not to ridicule, argue, or criticize it. Option 1 places the client in a defensive position by asking "why." Option 2 encourages the client to expound on the belief when discussion should instead be limited. Option 4 threatens the client. An older client is seen in the clinic for a physical examination. Laboratory studies reveal that the hemoglobin and hematocrit levels are low, indicating the need for further diagnostic studies and a blood transfusion. The client is a Jehovah's Witness and refuses to have a blood transfusion. The nurse should take which most appropriate action? Try to convince the client of the need for the transfusion. Speak to the family regarding the need for a blood transfusion. Support the client's decision not to receive a blood transfusion. Discuss with the client the results of the hemoglobin and hematocrit levels compared with normal levels. - Correct Answer-Support the client's decision not to receive a blood transfusion. Rationale: A client's cultural and ethnic background influences the response to health, illness, surgery, and death. Awareness of cultural differences enhances the nurse's knowledge of how a health care experience may be perceived by the client or family. In the Jehovah's Witness religion, the administration of blood and blood products is forbidden; therefore the nurse would support the client's decision. Trying to convince the client of the need for the blood transfusion is inappropriate and does not respect the client's cultural beliefs. Speaking to the family is a violation to the client's right to confidentiality; in addition, it does not respect the client's cultural beliefs. Discussing the results of laboratory values is an indirect way of trying to convince the client of the need for a blood transfusion, which again is inappropriate and does not respect the client's cultural beliefs. A nurse is monitoring an infant for signs of increased intracranial pressure (ICP). On assessment of the fontanelles, the nurse notes that the anterior fontanelle bulges when the infant is sleeping. Based on this finding, which is the priority nursing action? Increase oral fluids. Document the finding. Notify the health care provider. Place the infant supine in a side-lying position. - Correct Answer-Notify the health care provider. Rationale: The anterior fontanelle is diamond shaped and is located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. A larger-than-normal fontanelle may be a sign of increased ICP within the skull. Although the anterior fontanelle may bulge slightly when the infant cries, bulging at rest may indicate increased ICP. Options 1 and 4 are inaccurate interventions and will not be helpful. Although the nurse would document the finding, the priority action would be to report the finding to the health care provider. Methylergonovine (Methergine) is prescribed for a woman with postpartum hemorrhage caused by uterine atony. Before administering the medication, the nurse should check which most important client parameter? Lochial flow Urine output Temperature Blood pressure - Correct Answer-Blood pressure Rationale: Methylergonovine is an ergot alkaloid used for postpartum hemorrhage. It stimulates contraction of the uterus and causes arterial vasoconstriction. Ergot alkaloids are avoided in women with significant cardiovascular disease, peripheral disease, hypertension, eclampsia, or preeclampsia. Such conditions are worsened by the vasoconstrictive effects of the ergot alkaloids. The nurse would assess the woman's blood pressure before administering the medication and would follow agency protocols regarding withholding of the medication. Options 1, 2, and 3 are items that are assessed in the postpartum period, but they are unrelated to the use of this medication. A nurse is monitoring a newborn infant who has been circumcised. The nurse notes that the infant has a temperature of 100.6° F and that the dressing at the circumcised area is saturated with a foul-smelling drainage. Which is the priority nursing action? Reinforce the dressing. Document the findings. Contact the health care provider. Swab the drainage and send the sample to the laboratory for culture. - Correct AnswerContact the health care provider. Rationale: Complications after circumcision include bleeding, failure to urinate, displacement of the Plastibell, and infection (indicated by a fever and a purulent or foul-smelling drainage). If signs of infection occur, the health care provider is notified. The nurse would change, not reinforce, the dressing; reinforcing the dressing leaves the foul smelling drainage in contact with the surgical site. The nurse would document the findings, but this is not the priority item. The health care provider will prescribe a culture if it is necessary; it is not within the realm of nursing responsibilities to prescribe a diagnostic test. The nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement which type of precautions? Enteric Contact Droplet Neutropenic - Correct Answer-Droplet Rationale: A major priority in nursing care for a child with suspected meningitis is to administer the appropriate antibiotic as soon as it is prescribed. The child will be placed in a private room, with droplet transmission precautions, for at least 24 hours after antibiotics are given. Enteric, contact, and neutropenic precautions are not associated with the mode of transmission of meningitis. Enteric precautions are instituted when the mode of transmission is through the gastrointestinal tract. Contact precautions are instituted when contact with infectious items or materials is likely. Neutropenic precautions are instituted when the client has a low neutrophil count. The clinic nurse reads the results of a tuberculin skin test performed on a 5-year-old child who is at low risk for contracting tuberculosis. The results indicate an area of induration measuring 10 mm. How would the nurse interpret these results? Positive Negative Inconclusive Definitive and requiring a repeat test - Correct Answer-Negative Rationale: Induration measuring 15 mm or greater is considered a positive result in a child 4 years of age or older who has no associated risk factors. Options 1, 3, and 4 are incorrect interpretations. After a tonsillectomy, a child is brought to the pediatric unit. The nurse should appropriately place the child in which position? Prone Supine High Fowler's Trendelenburg - Correct Answer-Prone Rationale: The child should be placed in a prone or side-lying position after tonsillectomy to facilitate drainage. Options 2, 3, and 4 will not achieve this goal. A nurse is monitoring a 7-year-old child who sustained a head injury in a motor vehicle crash for signs of increased intracranial pressure (ICP). The nurse should assess the child frequently for which early sign of increased ICP? Continues...