Saunders NCLEX Questions
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1. The evening nurse reviews the nurs- d. Partial-thickness skin loss of the dermis
ing documentation in the client's
chart and notes that the day nurse Rationale: in a stage II pressure ulcer, the skin is not
has documented that the client has intact. Partial-thickness skin loss of the dermis has
a stage 2 pressure ulcer in the sacral occurred. It presents as a shallow-open ulcer with
area. Which of the following would a red-pink wound bed, without slough. It may also
the nurse expect to note on assess- present as an intact, open or ruptured, serum-filled
ment of the client's sacral area? blister. The skin is intact in stage I. Full-thickness skin
loss occurs in stage III. Exposed bone, tendon, or
a. Intact skin muscle is present in stage IV.
b. Full-thickness skin loss
c. Exposed bone, tendon, or muscle
d. Partial-thickness skin loss of the
dermis
2. A nurse is preparing a teaching plan c. Apply a moisturizing lotion to dry feet but not
for a client with DM regarding proper between the toes
foot care. Which instruction is includ-
ed in the plan? Rationale: the client is instructed to use a moisturiz-
ing lotion on the feet and to avoid applying the lotion
a. Soak feet in hot water between the toes. The client should be instructed
b. Avoid using a mild soap on the feet not to soak the feet and should avoid hot water to
c. Apply a moisturizing lotion to dry prevent burns. The client may cut the toenail straight
feet but not between the toes across and even with the toe itself and would consult
d. Always have a podiatrist cut your a podiatrist at the toenails were thick or hard to cut
toenails; never cut them yourself or if vision were poor. The client should be instructed
to wash the feet daily with a mild soap.
3. A client newly diagnosed with DM d. Systemically rotate insulin injections within one
has been stabilized with daily insulin anatomic site
injections. A nurse prepares a dis-
charge teaching plan regarding the Rationale: insulin doses should not be adjusted nor
, Saunders NCLEX Questions
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insulin and plans to reinforce which of increased before unusual exercise. If ketones are
the following concepts? found in the urine, it possibly may indicate the need
for additional insulin. To minimize the discomfort
a. Always keep insulin vials refrigerat- associated with insulin injections, insulin should be
ed administered at room temperature. Injection sites
b. Ketones in the urine signify a need should be rotated systematically within one anatom-
for less insulin ic site.
c. Increase the amount of insulin be-
fore unusual exercise
d. Systemically rotate insulin injec-
tions within one anatomic site
4. A client with a diagnosis of diabetic d. Elevated blood glucose level an low plasma bicar-
ketoacidosis (DKA) is being treated in bonate level
an emergency room. Which finding
would a nurse expect to note as con- Rationale: in DKA, the arterial pH is lower than 7.35,
firming this diagnosis? plasma bicarbonate is a lower than 15 mEq/L, the
blood glucose level is higher than 250 mg/dL, and
a. Comatose state ketones are present in the blood in urine. The client
b. Decreased urine output would be experiencing polyuria, and Kussmaul's
c. Increased respirations in an in- respirations would be present. A comatose state may
crease in pH occur if DKA is not treated, but coma would not
d. Elevated blood glucose level an low confirm the diagnosis.
plasma bicarbonate level
5. In external insulin pump is prescribed d. Gives a small continuous dose of regular insulin
for a client with DM in the client ask subcutaneously, and the client can self-administer a
the nurse about the functioning of bolus with an additional dose from the pump before
the pump. The nurse bases the re- each meal
sponse on the information that the
pump: Rationale: an insulin pump provides a small continu-
ous dose of regular insulin subcutaneously through-
a. Is timed to release programmed out the day and night, and the client can self-admin-
Study online at https://quizlet.com/_8oolkr
1. The evening nurse reviews the nurs- d. Partial-thickness skin loss of the dermis
ing documentation in the client's
chart and notes that the day nurse Rationale: in a stage II pressure ulcer, the skin is not
has documented that the client has intact. Partial-thickness skin loss of the dermis has
a stage 2 pressure ulcer in the sacral occurred. It presents as a shallow-open ulcer with
area. Which of the following would a red-pink wound bed, without slough. It may also
the nurse expect to note on assess- present as an intact, open or ruptured, serum-filled
ment of the client's sacral area? blister. The skin is intact in stage I. Full-thickness skin
loss occurs in stage III. Exposed bone, tendon, or
a. Intact skin muscle is present in stage IV.
b. Full-thickness skin loss
c. Exposed bone, tendon, or muscle
d. Partial-thickness skin loss of the
dermis
2. A nurse is preparing a teaching plan c. Apply a moisturizing lotion to dry feet but not
for a client with DM regarding proper between the toes
foot care. Which instruction is includ-
ed in the plan? Rationale: the client is instructed to use a moisturiz-
ing lotion on the feet and to avoid applying the lotion
a. Soak feet in hot water between the toes. The client should be instructed
b. Avoid using a mild soap on the feet not to soak the feet and should avoid hot water to
c. Apply a moisturizing lotion to dry prevent burns. The client may cut the toenail straight
feet but not between the toes across and even with the toe itself and would consult
d. Always have a podiatrist cut your a podiatrist at the toenails were thick or hard to cut
toenails; never cut them yourself or if vision were poor. The client should be instructed
to wash the feet daily with a mild soap.
3. A client newly diagnosed with DM d. Systemically rotate insulin injections within one
has been stabilized with daily insulin anatomic site
injections. A nurse prepares a dis-
charge teaching plan regarding the Rationale: insulin doses should not be adjusted nor
, Saunders NCLEX Questions
Study online at https://quizlet.com/_8oolkr
insulin and plans to reinforce which of increased before unusual exercise. If ketones are
the following concepts? found in the urine, it possibly may indicate the need
for additional insulin. To minimize the discomfort
a. Always keep insulin vials refrigerat- associated with insulin injections, insulin should be
ed administered at room temperature. Injection sites
b. Ketones in the urine signify a need should be rotated systematically within one anatom-
for less insulin ic site.
c. Increase the amount of insulin be-
fore unusual exercise
d. Systemically rotate insulin injec-
tions within one anatomic site
4. A client with a diagnosis of diabetic d. Elevated blood glucose level an low plasma bicar-
ketoacidosis (DKA) is being treated in bonate level
an emergency room. Which finding
would a nurse expect to note as con- Rationale: in DKA, the arterial pH is lower than 7.35,
firming this diagnosis? plasma bicarbonate is a lower than 15 mEq/L, the
blood glucose level is higher than 250 mg/dL, and
a. Comatose state ketones are present in the blood in urine. The client
b. Decreased urine output would be experiencing polyuria, and Kussmaul's
c. Increased respirations in an in- respirations would be present. A comatose state may
crease in pH occur if DKA is not treated, but coma would not
d. Elevated blood glucose level an low confirm the diagnosis.
plasma bicarbonate level
5. In external insulin pump is prescribed d. Gives a small continuous dose of regular insulin
for a client with DM in the client ask subcutaneously, and the client can self-administer a
the nurse about the functioning of bolus with an additional dose from the pump before
the pump. The nurse bases the re- each meal
sponse on the information that the
pump: Rationale: an insulin pump provides a small continu-
ous dose of regular insulin subcutaneously through-
a. Is timed to release programmed out the day and night, and the client can self-admin-
