Saunders NCLEX-PN 8th Edition

The nurse is collecting data from a client in crisis and is determining the potential for self-harm. Which data would indicate that the client is a very high risk for suicide?

* A client has an immediate plan for a suicide attempt

The nurse is reinforcing teaching with a client who is having difficulty sleeping. Which bedtime snacks will help the client achieve a restful night's sleep? Select all that apply.

* A glass of warm milk * A cube of Swiss cheese * A cup of caffeine-free tea

Which of these clients are most likely to develop fluid (circulatory) overload? Select all that apply.

* A premature infant * A 101-year-old man * A client with heart failure * A client receiving renal dialysis

A client is admitted to a psychiatric unit for observation following severe anxiety attacks. On admission, the client states, "There's nothing wrong with me. I shouldn't even be here. I am taking up a room, and there is probably someone else who really needs it." Although the nurse interprets this response as denial, which findings support a severe level of anxiety? Select all that apply.

* Inability to think clearly * Inability to problem solve

The nurse is reviewing laboratory results of a digoxin level for the client taking digoxin. The digoxin level is 2.5 ng/mL, which indicates digoxin toxicity. Which signs and symptoms would the nurse note? Select all that apply.

* Nausea * Syncope * Bradycardia

The nurse is reinforcing instructions to a client and family regarding home care following cataract removal with lens implantation in the left eye. The nurse would provide the client with instructions to contact the surgeon promptly for which signs or symptoms? Select all that apply.

* New floaters * Increasing redness in the eye

After abdominal surgery, a client experiences an evisceration. Which client statement supports this diagnosis?

*"It felt like something just slit me wide open"

The nurse is obtaining the report for a group of assigned clients. The nurse plans to monitor the serum potassium levels in which clients at risk for hyperkalemia? Select all that apply.

*A client with a new burn *A client diagnosed with acute kidney injury (AKI)

The nurse is assisting in performing an arterial blood gas (ABG) analysis on a client. The nurse initially implements which intervention after the blood gas is drawn to minimize the risk for uncontrolled bleeding?

*Applying direct pressure to the site

The nurse obtains the vital signs on a postoperative client who just returned to the nursing unit. The client's blood pressure (BP) is 100/60 mm Hg, the pulse is 90 beats per minute, and the respiration rate is 20 breaths per minute. On the basis of these findings, which actions would the nurse take? Select all that apply.

*Ask how the client feels and inquire about any feelings of dizziness *Review the client record to determine time and type of analgesia *Review the client record to note the vital signs taken in the PACU

The nurse is caring for a client following an abdominal surgery performed 1 day ago. An intravenous (IV) line is infusing, and a nasogastric (NG) tube is in place and attached to low intermittent suction. The nurse monitors the client and notes that the bowel sounds are absent. The nurse would perform which actions? Select all that apply.

*Ask the client whether he has passed any flatus. *Document the finding and continue to check for bowel sounds.

The nurse reviews the client's laboratory results. Which abnormal findings would the nurse report? Select all that apply.

*Calcium 8.2 mg/dL *Potassium 6 mEq/L *Magnesium 2.9 mg/dL *Phosphorus 5.2 mg/dL

A clinic nurse is reviewing the record of a client recently diagnosed with a cataract. Which clinical manifestations associated with this disorder would the nurse expect to be documented in the client's record? Select all that apply.

*Increasing nearsightedness *Need for more light when reading *Painless progressive loss of vision

A 0.9% intravenous (IV) solution is prescribed for a client. The IV is to run at 100 mL/hr. The nurse prepares the solution, understanding that which are characteristics of this type of solution? Select all that apply.

*Is the same solution as sodium chloride 0.9% *Is used to administer red blood cell transfusion *Is used to treat hypotension due to fluid volume deficit Submit

A client is scheduled for a myelogram, and the nurse reinforces a list of instructions to the client regarding preparation for the procedure. Which instructions would the nurse include in the list? Select all that apply.

*Jewelry will need to be removed *An informed consent will need to be signed *Nonalcholic fluid intake should be increased after the procedure

The clinic nurse reads the results of a tuberculin skin test performed on a 5-year-old child. The results indicate an area of induration measuring 8 mm. Which correct interpretation would the nurse make about these results?

*Negative

A client who had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which nursing interventions would the nurse take? Select all that apply.

*Notify the registered nurse immediately *Document the client's complaint with the exact times *Prepare the client for the wound closure by notifying surgery department *Instruct the client to remain quiet and reassure the situation is being taken care of

The nurse is reading a client's urinalysis report. The nurse interprets which item found on the report to be considered abnormal? Select all that apply.

*Positive protein *Leukocyte esterase-positive *White blood cells, 10 per high-power screen

A client is admitted to the surgical unit postoperatively with a self-suction Jackson-Pratt wound drain in place. The nurse determines the drain is functioning correctly with which observations? Select all that apply.

*The bulb container is fully compressed *Bright red bloody drainage is present in the bulb container

The nurse is assisting in the care of a client for whom an arterial blood gas (ABG) must be drawn. The nurse notes that the person who draws the blood sample from the radial artery performs an Allen's test first. The nurse recognizes that this is being done to determine the adequacy of which circulations? Select all that apply.

*Ulnar circulation *Radial circulation