SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX TWO.

SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX TWO 1) The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. Which is a priority intervention? Elevate the legs higher than the heart. 2) The nurse in the medical unit is reviewing the laboratory test results for a client who has been transferred from the intensive care unit (ICU). The nurse notes that a cardiac troponin T assay was performed while the client was in the ICU. The nurse determines that this test was performed to assist in diagnosing which condition? Myocardial infarction 3) The nurse is caring for a client with cardiac disease who has been placed on a cardiac monitor. The nurse notes that the client has developed atrial fibrillation and has a rapid ventricular rate of 150 beats/minute. The nurse should next assess the client for which finding? Hypotension 4) The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function? Listening to lung sounds 5) The nurse is participating in a class on rhythm strip interpretation. Which statement by the nurse indicates an understanding of a PR interval of 0.20? "This is a normal finding." 6) The nurse in the medical unit is assigned to provide discharge teaching to a client with a diagnosis of angina pectoris. The nurse is discussing lifestyle changes that are needed to minimize the effects of the disease process. The client continually changes the subject during the teaching session. The nurse interprets that this client's behavior is most likely related to which problem? An attempt to ignore or deny the need to make lifestyle changes 7) A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse should document that these findings identify which type of ulcer? An arterial ulcer 8) The nurse is developing a plan of care for a client who will be admitted to the hospital