Saunders NCLEX-PN

The nurse is reinforcing instructions to a client following mastectomy who will be discharged with an axillary drain in place. The client will be receiving home care visits from the nurse to monitor drainage and perform dressing changes. Which client statement indicates a need for further teaching?

"I need to begin full range-of-motion (ROM) exercises to my upper arm as soon as I get home."

The nurse is reinforcing instructions about home safety measures regarding medications and toxic substances to a parent. Which parent statements indicate a need for further teaching?

"I need to refer to medication as 'candy' only when really necessary." "I can place several medications in the same bottle if I am going for an overnight trip."

A client who has undergone barium enema is being readied for discharge. The nurse determines that the client has understood discharge instructions when the client makes which statement?

"I will be sure the barium passes and watch for my stools to return to normal."

The nurse is admitting a client to the hospital who has been scheduled for gastrointestinal (GI) surgery later in the day. When asking the client whether the client has taken any scheduled or over-the-counter medications in the past 24 hours, which statements would concern the nurse? Select all that apply.

"Yes, I take a full-strength aspirin every day." "I have taken my medication for my blood pressure this morning."

A client has been admitted to the hospital for urinary tract infection and dehydration. The nurse determines that the client has received adequate volume replacement if the blood urea nitrogen level drops to which value?

15 mg/dL (5.25 mmol/L)

The nurse has admitted a client to the clinical nursing unit following a right mastectomy. Which interventions would be included in the plan of care?

Elevate the right arm on one or two pillows. Ensure that no venipunctures or blood pressures (BPs) are done in the right arm.

The nurse is assisting in caring for a client with severe hyponatremia resulting from hypervolemia. The nurse anticipates which treatment would be prescribed by the primary health care provider?

Administer hypertonic normal saline solution intravenously.

A tuberculin skin test is administered to an individual infected with human immunodeficiency virus (HIV). Seventy-two hours later, the nurse checks the test site and documents the results as positive, indicating that the individual has been exposed to tuberculosis. Which findings did the nurse identify to make this interpretation?

An area of induration at the test site measuring 7 mm

The nurse who is caring for a client with kidney failure notes that the client is dyspneic, and crackles are heard when listening to breath sounds in the lungs. Which additional sign/symptom would the nurse expect to note in this client?

An increase in blood pressure

The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse would tell the client that which food item is least likely to contain calcium?

Butter

The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which sign/symptom would be an indication of this electrolyte imbalance?

Generalized muscle weakness

The nurse in the hospital is assisting in developing a plan of care for an older client to prevent a fall. Which actions would be least likely to prevent a fall?

Keeping the bathroom light off at nighttime Placing the client in the quiet area of the nursing unit in a room away from the nurse's station

The nurse is getting a postoperative client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action would the nurse take

Lower the head of the bed slowly until the dizziness is relieved.

Following a cleft lip repair, the nurse reinforces instructions to the parents of the infant. Which of the instructions would be given to the parents of the infant?

Monitor frequency of diaper changes. Cleanse the surgical site with normal saline. Apply prescribed antibiotic ointment to the surgical site.

A hospitalized client with heart disease who is taking digoxin has a digoxin level prescribed. The level is elevated above normal. Based on this finding the nurse plans to notify the registered nurse and primary health care provider (PHCP) and anticipates which additional interventions will be prescribed?

Monitor the potassium level. Place the client on cardiac monitor. Monitor the blood urea nitrogen (BUN) and creatinine.

The nurse is assisting in monitoring a client who may be started on parenteral nutrition (PN). The nurse reviews the client's laboratory results and determines that the client is at risk of severe malnutrition if the report indicates which critical level?

Serum albumin 2.8 g/dL

The nurse is caring for a client who becomes agitated and begins to pull on a surgically placed abdominal drainage tube. The primary health care provider visits and prescribes restraints if needed. Which actions are appropriate to delegate to the assistive personnel (AP), who has completed the facility's education about care of the restrained client?

Socialize with the restrained client. Remove the restraint and perform range of motion activity. Reapply the restraint after assisting the client to the bathroom.

The nurse is reviewing the health records of assigned clients. The nurse would plan care knowing that which client is at risk for fluid volume deficit?

The client with an ileostomy

In developing a plan of care for a client hospitalized with tuberculosis (TB), the nurse would place emphasis on which intervention?

The strict adherence to following airborne precautions

The nurse is observing a nursing student preparing to obtain a throat culture on a client suspected of having a beta-hemolytic Streptococcus infection. Which actions indicate the need for further teaching regarding collecting this specimen?

The student asks the client to tilt the head forward and to open the mouth. The student places the collection swab initially at the back of the client's tongue.

The nurse is caring for a Jewish client who follows a kosher diet. Which foods would the nurse use in planning meals for the client?

Tuna Chicken Apples Potatoes

The nurse is checking a client's surgical incision and notes an increase in the amount of drainage, a separation of the incision line, and the appearance of underlying tissue. Which actions would the nurse take to deal with this event?

Apply a sterile dressing soaked with normal saline to the wound. Notify the registered nurse (RN) and primary health care provider (PHCP) at once.

The nurse is changing the abdominal dressing on a client following abdominal surgery. The nurse notes that the incision line is separated and the appearance of underlying tissue is noted. Wound dehiscence is suspected. Which is the appropriate initial nursing action?

Apply a sterile dressing soaked with sterile normal saline to the wound.

The nurse just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit after abdominal surgery. The client has an indwelling urinary catheter in place. The vital signs are temperature 99.6°F (37.6°C), pulse 104 beats per minute, respirations 16 breaths per minute, and blood pressure (BP) 100/70 mm Hg. Urinary output is 20 mL for the past hour. Based on this data, which actions would the nurse take before notifying the registered nurse?

Review vital signs from previous hour. Observe the urinary catheter for patency and flow. Observe the IV site for patency and correct flow rate. Review when the client last received pain medication.