NCLEX Practice- Saunders Questions with Corrrect Answers

The nurse notes blanching, coolness, and edema at the peripheral IV site. On the basis of these findings, the nurse should implement which action? 1. remove the IV 2. apply a warm compress 3. check for blood return through the line 4. measure the area of infiltration Correct Answer 1. remove the IV - prevent any further damage that may be caused by infiltration The nurse has received the client assignments for the day. Which client should the nurse see first? 1. the client who needs SC insulin before breakfast 2. the client who has a NG tube set on intermittent suction 3. the client who is 2 days post-op and is complaining of pain at the incision site 4. the client with a blood glucose of 50 mg/dl and is complaining of blurred vision Correct Answer 4. the client with a blood glucose of 50 mg/dl and is complaining of blurred vision- hypoglycemia can be life threatening, so intervene and treat this first! The nurse prepares to care for a client on contact precautions admitted with MRSA. The client has an abdominal wound that requires irrigation and has a tracheostomy that is hooked up to a mechanical ventilator, which requires frequent suctioning. The nurse should don which protective equipment before entering the patient's room? 1. gloves and gown 2. gloves and face shield 3. gloves, gown, and face shield 4. gloves, gown, shoe protectors Correct Answer 3. gloves, gown, and face shield The nurse is choosing age-appropriate toys for a toddler. Which toy selection is the best choice for this age? 1. puzzle 2. toy soldiers 3. large stacking-blocks 4. card game with large pictures Correct Answer 3. large stacking-blocks- identify safety risks when interacting with smaller children- choking hazards, inability to comprehend rules, etc. A client diagnosed with coronary artery disease has selected guided imagery to help cope with the psychological stress caused from the diagnosis. Which statement made by the client indicates an understanding of this stress reduction measure? 1. "This will help only if I play music at the same time." 2. "This will work for me only if I am alone and in a quiet area." 3. "I need to do this only when I lie down in case I fall asleep." 4. "The best thing about this is that I can use it anywhere at anytime." Correct Answer 4. "The best thing about this is that I can use it anywhere at anytime." - guided imagery involves the client creating an image in the mind, concentrating on that image, and gradually becoming less aware of surrounding stimuli. A client with Parkinson's disease develops akinesia (freezing or no movement) while ambulating, increasing the risk for falls. Which suggestion by the nurse would cause the client to alleviate this problem? 1. use a wheelchair when moving around 2. stand erect and use a cane while ambulating 3. keep feet close together when walking and use a walker 4. consciously think about walking over imaginary lines on the floor Correct Answer 4. consciously think about walking over imaginary lines on the floor- clients with Parkinson's develop bradykinesia (moving slowly) or akinesia. Having these clients imagine lines on the floor to walk over can keep them moving forward while remaining safe. The nurse monitors a client receiving digoxin for which early manifestation of digoxin toxicity? 1. anorexia 2. facial pain 3. photophobia 4. jaundice Correct Answer 1. anorexia- digoxin is a cardiac glycoside used to manage/treat heart failure and A-fib. The most common early manifestations of toxicity include GI disturbances- nausea, vomiting, anorexia. A MRI is ordered for a patient with a suspected brain tumor. The nurse should implement which action to prepare the patient for this test? 1. shave the groin for insertion of a femoral catheter 2. remove all metal-containing objects from the client 3. keep the client NPO before procedure 4. instruct the client of inhalation techniques for the administration of the radioisotope. Correct Answer 2. remove all metal-containing objects from the client A client with renal insufficiency has a Mg+ level of 3.5 mEq/L. On the basis of this laboratory result, the nurse expects which client symptom? 1. hyperpnea 2. drowsiness 3. hypertension 4. physical hyperactivity Correct Answer 2. drowsiness- normal Mg+ level is 1.5-2.5 mEq/L. This client's level indicates hypermagnesemia- leads to neurological manifestations such as neurological depression- drowsiness, sedation, lethargy, muscle weakness, respiratory depression