Saunders NCLEX Questions Week 2

A child is seen in the school nurse's office with complaints of pain in the right forearm. In reviewing the child's record the nurse notes that that the child has a history of being physically abused by a parent. Which would be the initial intervention with this child?

Assess the child's physical status.

The nurse performs a physical assessment on a client and gathers both subjective and objective data. Which would the nurse document as subjective data?

Client reports difficulty sleeping at night.

The nurse is documenting the findings of a physical examination in a client's record. Which of the findings would the nurse determine to be objective data?

The client has a rash on the chest and arms.

The emergency department nurse is performing an assessment on a child suspected of being sexually abused. Which assessment data obtained by the nurse most likely support this suspicion?

difficulty walking

The nurse is assessing a client who takes ibuprofen for pain. The nurse is gathering information on the client's medication history and determines it is necessary to notify the primary health care provider (PHCP) if the client is also taking which medications? Select all that apply.

warfarin, glimepiride, and amlodipine

The nursing instructor is discussing the topic of pain with a student nurse who is assessing the status of pain in a cognitively impaired older adult. What comment by the student implies that further education is needed?

Clients in this age group are less sensitive to pain and have a greater pain tolerance.

The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/min. On the basis of this finding, which action is most appropriate?

Document the findings.

The nurse is explaining the appropriate methods for measuring an accurate temperature to an assistive personnel (AP). Which method, if noted by the AP as being an appropriate method, indicates the need for further teaching?

Taking an oral temperature for a client with a cough and nasal congestion

The nurse is instructing a client about receiving patient-controlled analgesia to control postoperative pain. What comment by the client indicates that further instruction is needed?

That's great that overdosing can't happen.

The nurse is caring for a client who is receiving morphine sulfate by the intravenous route for acute pain. The nurse ensures that which medication is available in the event that the client's respiratory status and level of consciousness deteriorate?

Naloxone

The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain needs to include which assessment?

The client's pain rating

The clinic nurse is preparing to perform a Romberg test on a client being seen in the clinic. The nurse would perform this test for the purpose of determining which status?

The functional status of the vestibular apparatus in the inner ear

A nurse is precepting a new graduate nurse, and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management?

"I will be sure to cue in to any indicators that the client may be exaggerating pain."

The registered nurse (RN) is educating a new RN on conducting a problem-based or focused assessment on a client. Which statement by the new RN indicates that the teaching has been effective?

"This is mostly used in a walk-in clinic or emergency department."

A 52-year-old male client is seen in the primary health care provider's (PHCP's) office for a physical examination after experiencing unusual fatigue over the last several weeks. The client's height is 5 ft, 8 in (173 cm) and his weight is 220 lb (99.8 kg). Vital signs are as follows: temperature, 98.6° F (37° C) orally; pulse, 86 beats/min; and respirations, 18 breaths/min. The blood pressure reading is 184/100 mm Hg. A random blood glucose level is 122 mg/dL (6.8 mmol/L). Which question would the nurse ask the client first?

"When was the last time you had your blood pressure checked?"

The nurse is assessing the status of pain in an alert older client who was recently admitted to the hospital with a diagnosis of ruptured lumbar disc. What are some of the beliefs and concerns older adults have about pain? Select all that apply.

- Pain is something that must be lived with. - Nurses are too busy to listen to reports of pain. - Pain signifies a serious illness or impending death. - Reporting pain will result in being labeled as a "bad" client.

The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2° F (36.2° C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action would the nurse take next?

Attempt to arouse the client.

The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesía (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temperature 97.2° F (36.2° C) orally, pulse 52 beats per minute, blood pressure 101/58 mm Hg, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action would the nurse take first?

Attempt to arouse the client.

The nurse is obtaining a pulse oximetry reading from a postoperative client who appears short of breath. The client has dark fingernail polish on top of artificial nails. What is the most appropriate action?

Obtain a pulse oximetry reading from another appropriate area, such as an earlobe.

The nurse is discussing pain management with a student who is caring for a one-day postoperative abdominal surgery client who is a known opioid substance abuser. What comment by the student indicates a need for further education?

Opioid substance abusers are less tolerant to opioids and require decreased doses.

The baseline vital signs for a client with pneumonia are as follows: temperature 98.8° F (37.1" C) oral, pulse 74 beats/min, respirations 18 breaths/min, and blood pressure 124/76 mm Hg. The client's temperature suddenly spikes to 103° F (39.4° C). Which corresponding respiratory rate would the nurse anticipate in this client as part of the body's response to the change in status?

Respiratory rate of 22 breaths/min

The nurse works in a long-term care facility, caring for older clients. The nurse would make which interpretation when an older client complains of pain?

Something is wrong, and an assessment needs to be made.

The nurse is setting up a transcutaneous electrical nerve stimulation unit on a client with chronic pain. As the nurse turns up the level of stimulation, the client complains of discomfort. Based on this finding, the nurse would make which interpretation?

The maximal stimulation has been reached, and it needs to be decreased slightly

The nurse prepares to take the blood pressure of a school-age child. To obtain an accurate measurement, how would the nurse position the blood pressure cuff?

Two thirds of the distance between the antecubital fossa and the shoulder