Saunders NCLECX Review
The nurse is performing an assessment on a female client who complains of fatigue, weakness, muscle and joint pain, anorexia, and photosensitivity. Systemic lupus erythematosus (SLE) is suspected. What should the nurse further assess that also is indicative of SLE?
A butterfly rash on the cheeks and bridge of the nose is an essential sign of SLE.
Terbutaline is prescribed for a client with bronchitis. The nurse understands that this medication should be used with caution if which medical condition is present in the client?
Diabetes mellitus It should be used with caution in clients with impaired cardiac function, diabetes mellitus, hypertension, hyperthyroidism, or a history of seizures. The medication may increase blood glucose levels.
Acetylcysteine (Mucomyst) is prescribed for a client in the hospital emergency department after diagnosis of acetaminophen (Tylenol) overdose. The nurse prepares to administer the medication using which procedure?
Diluting the medication in cola and administering it to the client orally Acetylcysteine can be given orally or by nasogastric tube to treat acetaminophen overdose.
A client is diagnosed with a full-thickness burn. The nurse understands that which structural areas of the skin are involved?
Epidermis, entire dermis, and epithelial portion of subcutaneous fat
A client is taking a monoamine oxidase inhibitor (MAOI). What is the primary reason the nurse needs to assess this client closely?
Headache, hypertension, and nausea and vomiting may indicate toxicity.
The nurse is performing an assessment on a client with the diagnosis of Brown-Séquard syndrome(hemisection of spinal cord). The nurse would expect to note which assessment finding?
Ipsilateral paralysis and loss of touch and vibration
Breathing exercises and postural drainage are prescribed for a hospitalized child with cystic fibrosis (CF). What instruction should the nurse include in the client's teaching plan?
Perform the postural drainage first and then the breathing exercises Perform the postural drainage first and then the breathing exercises
AKI caused by glomerulonephritis is classified as intrinsic or intrarenal failure
This form of AKI commonly manifests with hypertension, tachycardia, oliguria, lethargy, edema, and other signs of fluid overload
The normal level for glycosylated hemoglobin A1c is 4% to 5.9%
This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose.
Foods that decrease lower esophageal sphincter (LES) pressure and irritate the esophagus will increase reflux and exacerbate the symptoms of gastroesophageal reflux disease (GERD) and therefore should be avoided.
chocolate, coffee, fried or fatty foods, peppermint, carbonated beverages, and alcohol.
AKI from prerenal causes
decreased blood pressure or a recent history of the same, tachycardia, and decreased cardiac output and central venous pressure
Tamoxifen citrate is an antiestrogen and antineoplastic medication
may increase the calcium level and lower the low-density lipoprotein levels. Before the initiation of therapy, the complete blood count (CBC), platelet count, and serum calcium levels should be determined
The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. What intervention is the priority before the client is permitted to drink or eat?
If a client with a tracheostomy is allowed to eat and the tracheostomy has a cuff, the nurse should inflate the cuff to prevent aspiration of food or fluids
A clinic nurse is assessing the status of jaundice in a child with hepatitis. Which anatomical area will provide the best data regarding the presence of jaundice?
best assessed in the sclera, nail beds, and mucous membranes. Generalized jaundice will appear in the skin throughout the body.
Early manifestations of dumping syndrome occur 5 to 30 minutes after eating
Symptoms include vertigo, tachycardia, syncope, sweating, pallor, palpitations, and the desire to lie down.
An adult client has been defibrillated three times unsuccessfully for ventricular fibrillation, and cardiopulmonary resuscitation (CPR) is resumed. The nurse confirms that CPR is being administered effectively by noting which action?
The carotid pulse is palpable with each compression.
