NCLEX SAUNDERS CONTENT AREA

The nurse reinforces instructions to a client who is to return to the primary health care provider's office in 1 week for a patch test to identify the allergen causing the dermatitis. The nurse provides which instruction to the client?

"Discontinue the prescribed antihistamine 2 days before the test."

The nurse is planning to administer an oral glucose tolerance test (OGTT) to a client to rule out or confirm diabetes mellitus. The nurse knows that the client needs more information when the client makes which statements? Select all that apply.

"I can at least drink fluids during the test." "I have 30 minutes to drink the glucose load "I will have blood drawn every 5 minutes for the next 3 hours." rationale With an oral glucose tolerance test, the client should have fasted for 10 to 12 hours. After a fasting blood sample is obtained, the client consumes a 75-g or 100-g glucose load in 5 minutes. Blood is drawn every 30 minutes for 2 or 3 hours, depending on the glucose load. During the test, the client may not eat, drink, or smoke.

The nurse is caring for a client with a diagnosis of cancer who is immunosuppressed. The nurse would suggest to the registered nurse the need for implementing neutropenic precautions if the client's white blood cell count was which value?

2000 mm3 (2.0 × 109/L)

A client is scheduled for endoscopic retrograde cholangiopancreatography (ERCP). The nurse includes which intervention in the plan of care for the client?

After the procedure, keep the client nothing by mouth (NPO) until the gag reflex returns.

An abdominal postoperative client has been tolerating a full liquid diet, and the nurse plans to advance the diet to solid food as prescribed. The nurse collects data regarding which important item before advancing the diet to solids?

Dentition and ability to chew

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin (aPTT) time is 65 seconds. The licensed practical nurse reviews the laboratory results with the registered nurse, anticipating that which action is needed?

Leaving the rate of the heparin infusion as is

A client has just undergone a gastroscopy. Which action would be taken by the nurse as the essential postpro cedure nursing intervention?

Monitoring for the gag reflex

The client is having a lumbar puncture (LP) performed. The nurse would place the client in which position for the procedure?

Side-lying, with legs pulled up and chin to the chest

A client receiving total parenteral nutrition (TPN) asks the nurse if he has developed diabetes when the capillary blood glucose level is monitored and he is given insulin. The nurse explains that which is the reason for monitoring glucose levels and administering insulin?

TPN contains concentrated carbohydrates and raises blood glucose.

The nurse is reinforcing instructions to a client regarding how to decrease the intake of phosphorus in the diet. The nurse would tell the client that which food items are allowed with few restrictions in a phosphorus-restricted diet? Select all that apply.

apples withe bread eggs withes

A client with a history of gastrointestinal bleeding has a platelet count of 300,000 mm3 (300 × 109/L). The nurse would take which action after seeing the laboratory results?

Place the normal report in the client's medical record.

The nurse reinforces instructions regarding diet for a client at risk for hypokalemia. The nurse determines there is a need for further teaching when the client selects which foods as sources high in potassium? Select all that apply.

Bread and butter2Carrots and peas3Peppers and onions

A postoperative client has been placed on a clear liquid diet. Which items is the client allowed to consume? Select all that apply.

Broth2 Coffee Gelatin

Which action would the nurse include in the plan of care for a client following a renal scan?

No special precautions are needed except to wear gloves if coming into contact with the client's urine.

A gastric analysis is prescribed for a client with a suspected diagnosis of tuberculosis (TB). The nurse understands that the test is relevant in confirming this diagnosis because of which related fact?

People can frequently swallow small amounts of sputum.

A client scheduled for a pulmonary angiography is fearful about the procedure and asks the nurse if the procedure involves significant pain and radiation exposure. The nurse gives a response to the client that provides reassurance, based on which understanding?

Discomfort may occur with needle insertion, and there is minimal exposure to radiation.

A client is scheduled for an oral cholecystography. The nurse would plan to obtain what type of diet for the evening meal before the test?

Fat-free

A bone marrow aspiration is scheduled for a client suspected of having leukemia. What intervention does the nurse anticipate will be done to protect the aspiration site and client from becoming infected?

The site will be cleansed thoroughly with an antiseptic and allowed to air dry before the procedure.

A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas (ABG) determination. The nurse assists with performing Allen's test before drawing the blood to determine the adequacy of which?

Ulnar circulation

A client with leukemia who had a bone marrow aspiration is thrombocytopenic. The nurse gives which instruction to the family as the client is discharged to home?

Watch the puncture site for bleeding for the next several days.

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

A client will undergo a barium swallow to confirm a diagnosis of a hiatal hernia. In preparation for the test, which instruction would the nurse provide the client?

Avoid eating or drinking after midnight before the test.

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. Nonalcoholic fluid intake should be increased after the procedure.

A primary health care provider (PHCP) has written a prescription for a preoperative client to have "enemas until clear." The nurse has administered three enemas, and the client is still passing brown liquid stool. Which action would the nurse take next?

Notify the primary health care provider.

A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 9%. On the basis of this test result, the nurse plans to reinforce teaching the client about the need for which measure?

Preventing and recognizing hyperglycemia