Saunders NCLEX Questions And Answers Verified Solutions

Saunders NCLEX Questions And Answers Verified Solutions The nurse is assessing a client's postoperative pain using the PQRSTU method. Using this method, which questions would the nurse ask the client? 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. The nurse is preparing to administer furosemide (Lasix) to a client with a diagnosis of heart failure. Which is the most important laboratory test result for the nurse to check before administering this medication? 1-Blood urea nitrogen 2-Cholesterol level 3-Potassium level 4-Creatinine level Furosemide is a loop diuretic. The medication causes a decrease in the client's electrolytes, especially potassium, sodium, and chloride. Administering furosemide to a client with low electrolyte levels could precipitate ventricular dysrhythmias. Options 1 and 4 reflect renal function. The cholesterol level is unrelated to the administration of this medication. A nurse caring for a client with a diagnosis of gastrointestinal (GI) bleeding reviews the client's laboratory results and notes a hematocrit level of 30%. Which action should the nurse take? 1-Report the abnormally low level. 2-Report the abnormally high level. 3-Inform the client that the laboratory result is normal. 4-Place the normal report in the client's medical record. 1-Report the abnormally low level. The normal hematocrit level in a male ranges from 42% to 52%, and 35% to 47 % in a female, depending on age. A hematocrit level of 30% is a low level and would be reported to the health care provider because it indicates blood loss; therefore options 2, 3, and 4 are incorrect. A nurse provides dietary instructions to a client who will be taking warfarin sodium (Coumadin). The nurse should tell the client to avoid which food item? 1-Grapes 2-Spinach 3-Watermelon 4-Cottage cheese 2-Spinach Warfarin sodium is an anticoagulant. Anticoagulant medications act by antagonizing the action of vitamin K, which is needed for clotting. When a client is taking an anticoagulant, foods high in vitamin K often are omitted from the diet. Vitamin K-rich foods include green leafy vegetables, fish, liver, coffee, and tea. A client who has been receiving total parenteral nutrition (TPN) by way of a central venous access device complains of chest pain and dyspnea. The nurse quickly assesses the client's vital signs and notes that the pulse rate has increased and the blood pressure has dropped. The nurse determines that the client is most likely experiencing which problem? 1-Sepsis 2-Air embolism 3-Fluid overload 4-Fluid imbalance 2-Air embolism The signs and symptoms of air embolism include chest pain, dyspnea, hypoxia, anxiety, tachycardia, and hypotension. The nurse also may hear a loud churning sound over the pericardium on auscultation of the client's chest. The signs and symptoms of sepsis include fever, chills, and general malaise. Fluid overload causes increased intravascular volume, which increases the blood pressure and the pulse rate as the heart tries to pump the extra fluid volume. Fluid overload also causes neck vein distention and shifting of fluid into the alveoli, resulting in lung crackles. The signs and symptoms of a fluid imbalance depend on the type of imbalance the client is experiencing. A client who is receiving intravenous (IV) fluid therapy complains of burning and a feeling of tightness at the IV insertion site. On assessment, the nurse detects coolness and swelling at the site and notes that the IV rate has slowed. The nurse determines that which complication has occurred? Infection 2-Phlebitis 3-Infiltration 4-Thrombosis 1 An infiltrated IV line is one that has dislodged from the vein and is lying in subcutaneous tissue. Pallor, coolness, and swelling at the IV site result when IV fluid is deposited in the subcutaneous t issue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of IV solution will slow down or stop. The corrective action is to remove the catheter and start a new IV line at another site. The conditions identified in options 1, 2, and 4 are likely to be accompanied by warmth at the site, not coolness. A nurse provides instructions to a preoperative client about the use of an incentive spirometer. The nurse determines that the client needs further instruction if the client indicates that he or she will take which action? 1-Sit upright when using the device. 2-Inhale slowly, maintaining a constant flow. 3-Place the lips completely over the mouthpiece. 4-After maximal inspiration, hold the breath for 10 seconds and then exhale. inspiration, hold the breath for 10 seconds and then exhale. 4-After maximal For optimal lung expansion with the incentive spirometer, the client should assume a semi-Fowler's or high Fowler's position. The mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. When maximal inspiration is reached, the client should hold the breath for 2 or 3 seconds and then exhale slowly The nurse is monitoring a client who has a closed chest tube drainage system. The nurse notes f luctuation of the fluid level in the water-seal chamber during inspiration and expiration. On the basis of this finding, the nurse should make which interpretation? 1-There is a leak in the system. 2-The chest tube is functioning as expected. 3-The amount of suction needs to be decreased. 4-The occlusive dressing at the insertion site needs reinforcement. as expected. 2-The chest tube is functioning The presence of fluctuation of the fluid level in the water-seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if the suction is not working properly, or if the lung has re expanded. Options 1, 3, and 4 are incorrect interpretations of the finding. An air leak may cause excessive bubbling in the water seal chamber. Excessive and vigorous bubbling in the suction control chamber may indicate that the amount of suction needs to be decreased. The status of the dressing is not specifically related to the presence of fluctuation of the fluid level in the water-seal chamber A nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. The nurse immediately applies sterile gauze over the chest tube insertion site. Which is the nurse's next action? 1-Call the health care provider. 2-Replace the chest tube system. 3-Obtain a pulse oximetry reading. 4-Place the client in a Trendelenburg position 1-Call the health care provider. If the chest drainage system is dislodged from the insertion site, the nurse immediately applies sterile gauze over the site and calls the health care provider. The nurse would maintain the client in an upright position. A new chest tube system may be attached if the tube requires insertion, but this would not be the next action. Pulse oximetry readings would assist in determining the client's respiratory status, but the priority action would be to call the health care provider in this emergency situation. A nurse reviews the medication history of a client and notes that the client is taking leflunomide (Arava). During assessment of the client, the nurse should ask which question to determine the effectiveness of this medication? 1-"Do you have any joint pain?" 2-"Are you having any diarrhea?" 3-"Are you experiencing heartburn?" 4-"Do you have frequent headaches?" 1-"Do you have any joint pain?" Leflunomide is an immunomodulatory agent and has an anti-inflammatory action. The medication provides symptomatic relief of rheumatoid arthritis. Diarrhea can occur as a side effect of the medication. Options 2, 3, and 4 are unrelated to the action, use, or effectiveness of the medication. 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? 1-The client is hemorrhaging. 2-The client needs to increase oral fluids. 3-The client is experiencing normal lochia discharge. 4-The client's health care provider needs to be notified of the finding. normal lochia discharge. 3-The client is experiencing Lochia, the uterine discharge present after birth, initially is bright red and may