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SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX ONE 100% VERIFIED QUESTIONS AND ANSWERS SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX ONE 100% VERIFIED QUESTIONS AND ANSWERS SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX ONE 100% VERIFIED QUESTIONS AND ANSWERS SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX ONE 100% VERIFIED QUESTIONS AND ANSWERS SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX ONE 100% VERIFIED QUESTIONS AND ANSWERS
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Several laboratory tests are prescribed for a client, and the nurse reviews the results of the tests. Which laboratory test results should the nurse report? Select all that apply. ✓ Platelets 35,000 mm^3 (35 × 109 /L) ✓ Sodium 150 mEq/L (150 mmol/L) ✓ Segmented neutrophils 40% (0.40) ✓ White blood cells, 3000 mm^3 (3.0 × 10^9 /L)
A critically ill Hispanic client tells the nurse through an interpreter that she is Roman Catholic and firmly believes in the rituals and traditions of the Catholic faith. Based on the client's statements, which actions by the nurse demonstrate cultural sensitivity and spiritual support? Select all that apply.(1,2,5)
✓ Answers-Ensures that a close relative stays with the client
✓ Makes a referral for a Catholic priest to visit the client ✓ Offers to provide a means for praying the rosary if the client wishes.
Which clients have a high risk of obesity and diabetes mellitus? Select all that apply.(1,2,4,5) ✓ Latino American Man ✓ Native American man ✓ Hispanic American man ✓ African American woman
The nurse is preparing a plan of care for a client, and is asking the client about religious preferences. The nurse considers the client's religious preferences as being characteristic of a Jehovah's Witness if which client statement is made? ✓ I cannot have any food containing or Prepared with blood."
The ambulatory care nurse is discussing preoperative procedures with a Japanese American client who is scheduled for surgery the following week. During the discussion, the
client continually smiles and nods the head. How should the nurse interpret this nonverbal behavior?
✓ Encourage the client to discuss the use of an herbal substance with the health care provider (HCP).
✓ "Magnetic therapy and massage therapy are a focus of CAM."
✓ The client was found lying on the floor.
✓ Transport the victim to the operating room for surgery.
The nurse has just assisted a client back to bed aftera fall. The nurse and health care provider have assessed theclient and have determined that the client is not injured. After completing the incident report, the nurse should implement which action next?
✓ Answers-Continue with the instructions, verifying client understanding.
✓ The client slept through the night.
✓ Abdominal wound dressing is dry and intact without drainage.
✓ The client's left lower medial leg wound is 3 cm in length without redness, drainage, or edema.
✓ Observing care provided to the client without the client's permission
✓ Slander
✓ As a nurse, I am legally bound to report abuse. I will stay with you while you give the report and help find a safe place for you to stay."
✓ Contact the nursing supervisor.
✓ Call the nursing supervisor and report the incident.
✓ A client with asthma who requested a breathing treatment during the previous shift
✓ A client with chest pain who states that he just ate pizza that was made with a very spicy sauce
✓ A client who requires urine specimen collections
✓ Move beds away from windows.
✓ Close window shades and curtains.
✓ Place blankets over clients who are confined to bed.
✓ A client requiring abdominal wound irrigations and dressing changes every 3 hours
✓ The acuity level of the clients
✓ Client needs and workers' needs and abilities
manifestations would the nurse expect to note in this client if excess fluid volume is present?
✓ An increase in blood pressure and increased respirations
✓ Requires nasogastric suction
✓ U waves
✓ Inverted T waves
✓ Depressed ST segment
✓ Obtain an intravenous (IV) infusion pump.
✓ Monitor urine output during administration.
✓ Monitor the IV site for signsof infiltration or phlebitis.
✓ Ensure that the medication is diluted in the appropriate volume of fluid.
✓ Tall peaked T waves
✓ Widened QRS complexes
✓ The client who is taking diuretics
✓ Hyperactive bowel sounds
✓ Malnutrition
✓ Integumentary output
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✓ A client with an ileostomy
✓ Weight loss and poor skin turgor
✓ The client with kidney disease and a 12-year history of diabetes mellitus
Which client is at risk for the development of a potassium level of 5.5mEq/L (5.5 mmol/L)? ✓ The client who has sustained a traumatic burn
The nurse reviews the arterial blood gas results of a client and notes the following: pH 7.45, Paco 2 of 30 mm Hg (30 mm Hg), and HCO –^ of 20 mEq/L (20 mmol/L). The nurse analyzes these results as indicating which condition? ✓ Respiratory alkalosis, compensated
The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for? ✓ Metabolic alkalosis
A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/minute. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? ✓ An increased pH and an increased HCO 3 –
The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a Paco 2 of 30 mm Hg (30 mm Hg). The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? ✓ Potassium level of 3.0 mEq/L (3.0 mmol/L)
The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? ✓ Respiratory acidosis from inadequate ventilation
A client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium has a prothrombin time (PT) of 35 seconds and an international normalized ratio (INR) of 3.5. On the basis of these laboratory values, the nurse anticipates which prescription? ✓ Holding the next dose of warfarin
A staff nurse is precepting a new graduate nurse and the new graduate is assigned to care for a client with chronic pain. Which statement, if made by the new graduate nurse, indicates the need for further teaching regarding pain management? ✓ "I will be sure to cue in to any indicators that the client may be exaggerating their pain."
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 (BUN) level drops to which value? ✓ 15 mg/dL (5.25 mmol/L)
The nurse is explaining the appropriate methods for measuring an accurate temperature to an unlicensed assistive personnel (UAP). Which method, if noted by the UAP as being an appropriate method, indicates the need for further teaching?
✓ Taking an oral temperature for a client with a cough and nasal congestion
client's activated partial thromboplastin time (aPTT) is 65 seconds. The nurse anticipates that which action is needed?
The nurse instructs a client with chronic kidney disease who is receiving hemodialysis about dietary modifications. The nurse determines that the client understands these dietary modifications if the client selects which items from the dietary menu? ✓ Cream of wheat, blueberries, coffee
The nurse is conducting a dietary assessment on a client who is on a vegan diet. The nurse provides dietary teaching and should focus on foods high in which vitamin that may be lacking in a vegan diet? ✓ Vitamin B 12
A client with hypertension has been told to maintain a diet low in sodium. The nurse who is teaching this client about foods that are allowed should include which food item in a list provided to the client? ✓ Summer squash
A postoperative client has been placed on a clear liquid diet. The nurse should provide the client with which items that are allowed to be consumed on this diet? Select all that apply. ✓ Broth ✓ Coffee ✓ Gelatin
The nurse is instructing a client with hypertension on the importance of choosing foods low in sodium. The nurse should teach the client to limit intake of which food? ✓ Smoked sausage
A client who is recovering from surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been "bored" with the clear liquid diet. The nurse should offer which full liquid item to the client? ✓ Custard
A client is recovering from abdominal surgery and has a large abdominal wound. The nurse should encourage the client to eat which food item that is naturally high in vitamin C to promote wound healing? ✓ Oranges
The nurse is caring for a client with cirrhosis of the liver. To minimize the effects of the disorder, the nurse teaches the client about foods that are high in thiamine. The nurse determines that the client has
the best understanding of the dietary measures to follow if the client states an intention to increase the intake of which food? ✓ Legumes