Saunders NCLEX Questions

The nurse hangs a 1000-mL intravenous (IV) bag of 5% dextrose in water (D5W) at 0700. The IV solution is to infuse at 80 mL/hr. At 1200, how much solution will be left to infuse? Fill in the blank.

600 mL

The nurse is preparing a list of client care activities to be done during the shift. For which clients would the nurse instruct the assistive personnel (AP) to use an electric razor for shaving? Select all that apply. 1. A client with leukocytosis 2. A client with thrombocytosis 3. A client with thrombocytopenia 4. A client receiving an antiplatelet medication 5. A client receiving acetaminophen as needed for mild pain

(3,4 ) 3. A client with thrombocytopenia 4. A client receiving an antiplatelet medication

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? 1. Opioid substance abusers are less tolerant to opioids and require decreased doses. 2. These clients need to be allowed to choose their pain medications and dosing regimen. 3. Nonopioid therapies such as cutaneous stimulation are generally effective if used alone. 4. These clients are at an increased risk for abrupt physiological withdrawal when opioid agonists are abruptly withdrawn.

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

The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse needs to call the surgeon to clarify that which medication would be given to the client and not withheld? 1. Prednisone 2. Ferrous sulfate 3. Cyclobenzaprine 4. Conjugated estrogen

1. Prednisone

The nurse is talking to the parent of a 2-month-old infant who is being seen in the primary health care provider's office for a well-child visit. Which statement by the parent would indicate that further teaching is needed about nutrition for this infant? 1. "My family said to start my infant on a cup, but I think my infant is too young." 2. "I started my infant on cereal a week ago, and infant loves the rice cereal." 3. "I remembered that my infant needs to stay on formula for an entire year." 4. "My friend has a 4-month-old child, and I told my friend that I am not going to start solid food until my infant is at least 6 months old."

2. "I started my infant on cereal a week ago, and infant loves the rice cereal."

The nurse is reviewing the laboratory results of a client admitted to the hospital with a diagnosis of venous thrombosis. The nurse expects the platelet aggregation to be reported as which level in this client? 1. Normal 2. Increased 3. Decreased 4. Insignificant

2. Increased

A primary health care provider prescribes 1000 mL of normal saline to infuse over 8 hours. The drop factor is 10 drops (gtt)/mL. The nurse prepares to set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

21 gtt/min

A parent calls a neighbor who is a nurse and tells the nurse that their 3-year-old child has just ingested liquid furniture polish. The nurse would direct the parent to take which immediate action? 1. Induce vomiting. 2. Call an ambulance. 3. Call the Poison Control Center. 4. Bring the child to the emergency department.

3. Call the Poison Control Center.

The nurse has reviewed with the preoperative client the procedure for the administration of an enema. Which statement by the client would indicate the need for further instruction? 1. "The enema will be given while I am sitting on the toilet." 2. "I would try and hold the fluid as long as possible after it is run in." 3. "I know that there will be some cramping after the enema solution is run in." 4. "I would tell the nurse if cramping occurs when the fluid is running in."

1. "The enema will be given while I am sitting on the toilet."

The nurse is preparing for suctioning an unconscious client who has a tracheostomy. The nurse would perform which actions for this procedure? Select all that apply. 1. Keeping a supply of suction catheters at the bedside 2. Auscultating breath sounds to determine the need for suctioning 3. Hyperoxygenating the client before, during, and after suctioning 4. Intermittently suctioning during insertion of the suction catheter 5. Placing suction on the catheter for at least 30 seconds to ensure that all secretions are removed

1. Keeping a supply of suction catheters at the bedside 2. Auscultating breath sounds to determine the need for suctioning 3. Hyperoxygenating the client before, during, and after suctioning

The nurse is preparing to administer 30 mEq of liquid potassium chloride (KCl) to an adult client. The label on the medication bottle reads 40 mEq of KCl per 15 mL. The nurse would prepare how many milliliters of KCl to administer the correct dose of medication? Fill in the blank. Round your answer to the nearest whole number.

11 mL

A primary health care provider prescribes 1 unit of packed red blood cells to be infused over 4 hours. The unit of blood contains 250 mL. The drop factor is 15 drops (gtt)/mL. The nurse would set the flow rate at how many drops per minute? Fill in the blank. Round your answer to the nearest whole number.

16 gtt/min

An 85-year-old client is hospitalized for a fractured right hip. During the postoperative period, the client's appetite is poor and the client refuses to get out of bed. Which nursing statement would be most appropriate to make to the client? 1. "We need to give you iodine to help in hemoglobin synthesis." 2. "It is important for you to get out of bed so that calcium will go back into the bone." 3. "We need to increase your calcium intake because you are spending too much time in bed." 4. "You need to remember to turn yourself in bed every 2 hours to keep from getting so stiff."

2. "It is important for you to get out of bed so that calcium will go back into the bone."

A hydrocolloid dressing is prescribed for a client with a leg ulcer. The home health nurse is preparing a plan of care for the client and would appropriately document which intervention? 1. Change the hydrocolloid dressing daily. 2. Change the hydrocolloid dressing every 3 to 5 days. 3. Apply the hydrocolloid dressing over a dry, sterile dressing. 4. Apply the hydrocolloid dressing over a normal saline-soaked dressing.

2. Change the hydrocolloid dressing every 3 to 5 days.

A client being measured for crutches asks the nurse why the crutches cannot rest up underneath the arm for extra support. The nurse responds, knowing that which would most likely result from this improper crutch measurement? 1. A fall and further injury 2. Injury to the brachial plexus nerves 3. Skin breakdown in the area of the axilla 4. Impaired range of motion while the client ambulates

2. Injury to the brachial plexus nerves

A prescription reads 1000 mL of normal saline (NS) to infuse over 12 hours. The drop factor is 15 drops (gtt)/1 mL. The nurse prepares to set the flow rate at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

21 drops per minute

A nursing student is developing a plan of care for a client with a chest injury who has a chest tube that is attached to a chest drainage system. Which intervention in the care plan indicates the need for further teaching for the student? 1. Position the client in semi-Fowler's position. 2. Add water to the suction chamber as it evaporates. 3. Instruct the client to avoid coughing and deep breathing. 4. Tape the connection sites between the chest tube and the drainage system.

3. Instruct the client to avoid coughing and deep breathing.

A primary health care provider prescribes phenytoin 0.1 g orally 3 times a day. The nurse determines that the prescribed dosage is being administered if the client will be receiving a total of how many milligrams in a 24-hour period? Fill in the blank.

300 mg

A client has just returned from the cardiac catheterization laboratory. The left-sided femoral vessel was used as the access site. How would the nurse position the client? 1. Knee chest, with the foot of the bed elevated 2. Supine, with the head of the bed elevated 45 to 90 degrees 3. Semi-Fowler's, with the knees placed on top of 1 pillow 4. Supine, with the head of the bed elevated about 15 to 30 degrees

4. Supine, with the head of the bed elevated about 15 to 30 degrees

A prescription reads 1000 mL D5W to infuse at a rate of 125 mL/hr. The nurse determines that it will take how many hours for 1 L to infuse? Fill in the blank.

8 hours

A primary health care provider prescribes 3000 mL of 5% dextrose in water to run over a 24-hour period. The drop factor is 15 drops (gtt) per 1 mL. The nurse would adjust the flow rate to run at how many drops per minute? Fill in the blank. Record your answer to the nearest whole number.

31 gtt/min

The student nurse is caring for an infant with a tracheostomy and is preparing to suction the infant. The nursing instructor would intervene if the nursing student stated taking which action to perform this procedure? 1. Limit insertion and suctioning time to 15 seconds to prevent hypoxia. 2. Insert the catheter the length of the tracheostomy tube with the suction off. 3. Apply intermittent suction and withdraw the catheter with a twisting motion. 4. Reoxygenate between insertion passes with the suction catheter and allow sufficient recovery time with each pass.

1. Limit insertion and suctioning time to 15 seconds to prevent hypoxia.

The nurse is providing medication instructions to a parent. Which statement by the parent indicates a need for further instruction? 1. "I need to cuddle my child after giving the medication." 2. "I can give my child a frozen juice bar after my child swallows the medication." 3. "I need to mix the medication in the baby food and give it when I feed my child." 4. "If my child does not like the taste of the medicine, I need to encourage my child to pinch the nose and drink the medication through a straw."

3. "I need to mix the medication in the baby food and give it when I feed my child."

The nurse is caring for a client who is mechanically ventilated and is monitoring for complications of mechanical ventilation. Which assessment finding, if noted by the nurse, indicates the need for follow-up? 1. Muscle weakness in the arms and legs 2. A temperature of 98.6° F (37° C), decreased from 99.0° F (37.2° C) 3. A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg 4. A heart rate of 80 beats/minute, decreased from 85 beats/minute

3. A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg

A client is recovering from abdominal surgery and has a large abdominal wound. The nurse would encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing? 1. Milk 2. Oranges 3. Bananas 4. Chicken

2. Oranges