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NURSING Med Surg 2 SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FOUR. Contains 1141 NCLEX Commonly Tested Q&A With Rationale.

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NURSING Med Surg 2 SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FOUR 1) The nurse would anticipate that the health care provider (HCP) would add which medication to the regimen of the client receiving iso... niazid? 2) A postpartum nurse is caring for a client with an epidural catheter in place for opioid analgesic administration following cesarean birth. The client develops respiratory depression and requires naloxone administration. Which finding should the nurse anticipate as a result of the naloxone administration? 3) The nurse should monitor the client receiving the first dose of albuterol for which side or adverse effect of this medication? 4) The client has a prescription to receive pirbuterol 2 puffs and beclomethasone dipropionate 2 puffs by metered-dose inhaler. The nurse plans to give these medications in which way to ensure effectiveness? 5) A client with chronic obstructive pulmonary disease (COPD) is being changed from an oral glucocorticoid to triamcinolone by inhalation. The client asks why this change is necessary. Which statement by the nurse to the client is accurate? 6) A client taking theophylline has a serum theophylline level of 15 mcg/mL (60 mcmol/L). How does the nurse interpret this laboratory value? 7) A client is taking cetirizine. The nurse should inform the client of which side effect of this medication? 8) A client is scheduled to receive acetylcysteine 20% solution diluted in 0.9% normal saline by nebulizer. Which outcome would the nurse expect as a result of the administration of this medication? 9) The health care provider prescribes cromolyn for the client with asthma. The nurse identifies that the client correctly understands the purpose of this medication when the client states that the medication will produce which effect?  10) The nurse is teaching a client about the effects of diphenhydramine, an ingredient in the cough suppressant prescribed for the client. The nurse should plan to tell the client to take which measure while taking this medication? 11) The health care provider (HCP) has prescribed codeine sulfate for a client with a nonproductive cough to suppress the cough reflex. The nurse should teach the client to monitor for which side effect of the medication? 12) A client has begun therapy with a xanthine bronchodilator. The nurse determines that the client understands dietary alterations if the client states to limit which items while taking this medication? Select all that apply. 13) Which supplies should the nurse obtain for the administration of ribavirin to a hospitalized child with respiratory syncytial virus (RSV)? 14) The nurse is documenting information in a client's chart when the electrocardiogram telemetry alarm sounds, and the nurse notes that the client is in ventricular tachycardia (VT). The nurse rushes to the client's bedside and should perform which assessment first? 15) A client is brought into the emergency department in ventricular fibrillation (VF). The nurse prepares to defibrillate by placing defibrillation pads on which part of the chest? 16) An adult client has been unsuccessfully defibrillated for ventricular fibrillation, and cardiopulmonary resuscitation (CPR) is resumed. The nurse confirms that CPR is being administered effectively by noting which action 17) The nurse is assigned the care of a client who experienced a myocardial infarction and is being monitored by cardiac telemetry. The nurse notes the sudden onset of this cardiac rhythm on the monitor. The nurse should immediately take which action? Refer to Figure. View Figure 18) To perform defibrillation, the defibrillator pads should be placed in which areas of the client's chest? 19) The nurse is caring for a client who is pulseless and experiencing this dysrhythmia. Which interventions should the nurse anticipate implementing in collaboration with the health care provider (HCP)? Select all that apply. Refer to Figure. View Figure 20) The nurse is performing cardiopulmonary resuscitation (CPR) on a client who has had a cardiac arrest. An automatic external defibrillator (AED) is available to treat the client. Which activity will allow the nurse to assess the client's cardiac rhythm? 21) The nurse is teaching adult cardiopulmonary resuscitation (CPR) guidelines to a group of laypeople. The nurse observes the group correctly demonstrate 2-rescuer CPR when which ratio of compressions to ventilations is performed on the mannequin? 22) The nurse is teaching cardiopulmonary resuscitation (CPR) to a group of community members. The nurse tells the group that when chest compressions are performed on infants, the sternum should be depressed how far? 23) The nursing instructor teaches a group of students about cardiopulmonary resuscitation. The instructor asks a student to identify the most appropriate location at which to assess the pulse of an infant younger than 1 year of age. Which response would indicate that the student understands the appropriate assessment procedure? 24) The nurse is conducting a basic life support (BLS) recertification class and is discussing chest compressions in a pregnant woman. The nurse should tell the class that which action should be taken in an advanced pregnancy client whose fundal height is at or above the umbilicus? 25) The nurse is initiating 1-rescuer cardiopulmonary resuscitation on an adult client. The nurse should place the hands in which position to begin chest compressions? 26) The nurse walking in a downtown business area witnesses a worker fall from a ladder. The nurse rushes to the victim, who is unresponsive. A layperson is attempting to perform resuscitative measures. The nurse should intervene if which action by the layperson is noted? 27) The nurse notes that a 14-year-old child is choking but is awake and alert at this time. The nurse rushes to perform the abdominal thrust maneuver. The child becomes unconscious. What procedure should the nurse perform next? 28) The nurse assigned to the pediatric unit finds an infant unresponsive and without respirations or a pulse. What is the nurse's next action after calling for help? 29) The nurse is undergoing annual recertification in basic life support (BLS). The BLS instructor asks the nurse to identify the pulse point to use when determining pulselessness on an infant. Which response by the nurse identifies the most appropriate pulse point? 30) External public access defibrillator (PAD) interprets that the rhythm of a pulseless victim is ventricular fibrillation and advises defibrillation. Which action should the rescuer take next? 31) Cardiopulmonary resuscitation (CPR) is immediately initiated on a client who is unconscious and has no pulse. A monitor is attached and it is determined that the rhythm is shockable, and defibrillation with 1 shock is delivered. Which action should the nurse plan to take next? 32) The nurse has completed 5 cycles of compressions after beginning cardiopulmonary resuscitation (CPR) on a hospitalized adult client who experienced unmonitored cardiac arrest. What should the nurse plan to do next? 33) The nurse is teaching chest compressions for cardiopulmonary resuscitation (CPR) to a group of lay clients. Which behavior by one of the participants indicates a need for 34) In order of priority, how should the nurse perform abdominal thrusts on an unconscious adult? Arrange the actions in the order that they should be performed. All options must be used. 35) One unit of packed red blood cells has been prescribed for a client with severe anemia. The client has received multiple transfusions in the past, and it is documented that the client has experienced urticaria-type reactions from the transfusions. The nurse anticipates that which medication will be prescribed before administration of the red blood cells to prevent this type of reaction? 36) The nurse has a prescription to administer whole blood to a client who does not currently have an intravenous (IV) line inserted. When obtaining supplies to start the blood infusion, the nurse should select an angiocatheter of at least which size? 37) A client has experienced high blood pressure and crackles in the lungs during previous blood transfusions. The client asks the nurse whether it is safe to receive another transfusion. The nurse explains that which medication most likely will be prescribed before the transfusion is begun? 38) The nurse is told by a health care provider that a client in hypovolemic shock will require plasma expansion. The nurse should prepare which supplies for transfusion? 39) The nurse has discontinued a unit of blood that was infusing into a client because the client experienced a transfusion reaction. After documenting the incident appropriately, the nurse sends the blood bag and tubing to which department? 40) The nurse has just obtained a unit of blood from the blood bank to transfuse into a client as prescribed. Before preparing the blood for transfusion, the nurse looks for which member of the health care team to assist in checking the unit of blood? 41) The nurse is picking up a unit of packed red blood cells at the hospital blood bank. After putting the pen down, the nurse glances at the clock, which reads 1300. The nurse calculates that the transfusion must be started by which time? 42) The nurse enters a client's room to assess the client, who began receiving a blood transfusion 45 minutes earlier, and notes that the client is flushed and dyspneic. On assessment, the nurse auscultates the presence of crackles in the lung bases. The nurse determines that this client most likely is experiencing which complication of blood transfusion therapy? 43) The nurse is monitoring a client who is receiving a blood transfusion. After 30 minutes of the infusion, the client begins to have chills and back pain. His temperature is 100.1°F (37.8°C). What action should the nurse take first? 44) The nurse enters the room of a client who began receiving a blood transfusion 45 minutes earlier to check on the client. The client is complaining of "itching all over" and has a generalized rash. The client's temperature has not changed from baseline and the lungs are clear to auscultation. Which complication of blood transfusion therapy should the nurse determine that this client is most likely experiencing? 45) A unit of platelets was just received from the blood bank for transfusion to an assigned client. The nurse should select tubing with which feature for the transfusion? 46) The nurse overhears a health care provider (HCP) stating that a client diagnosed with disseminated intravascular coagulation (DIC) requires a transfusion. Which blood product should the nurse anticipate that the HCP will write a prescription for? 47) The nurse is assisting in monitoring a client who is receiving a transfusion of packed red blood cells (PRBCs). Before leaving the room, the nurse tells the client to immediately report which symptoms of a transfusion reaction? Select all that apply. 48) A child is receiving succimer for the treatment of lead poisoning. The nurse should monitor which most important laboratory result? 49) A client with a probable minor head injury resulting from a motor vehicle crash is admitted to the hospital for observation. The nurse leaves the cervical collar applied to the client in place until when? 50) A client experienced an open pneumothorax (sucking wound), which has been covered with an occlusive dressing. The client begins to experience severe dyspnea, and the blood pressure begins to fall. The nurse should first perform which action? 51) The nurse is performing an assessment on a client admitted to the nursing unit who has sustained an extensive burn injury involving 45% of total body surface area. When planning for fluid resuscitation, the nurse should consider that fluid shifting to the interstitial spaces is greatest during which time period? 52) The nurse in the recovery room is caring for a client who underwent neurosurgery. Sequential compression devices (SCDs) have been applied to prevent venous stasis. While awaiting client transfer to the intensive care unit, the recovery room nurse should perform which critical assessment? 53) A pulmonary artery catheter is inserted into a client during cardiac surgery. The nurse is monitoring the right atrial pressure (RAP). Which finding requires immediate nursing intervention? 54) The nursing educator has just completed a lecture to a group of nurses regarding care of the client with a burn injury. A major aspect of the lecture was care of the client at the scene of a fire. Which statement, if made by a nurse, indicates a need for further instruction? 55) The community health nurse is providing a teaching session to firefighters in a small community regarding care of a burn victim at the scene of injury. The nurse instructs the firefighters that in the event of a tar burn, which is the immediate action? 56) The industrial nurse is providing instructions to a group of employees regarding care to a client in the event of a chemical burn injury. The nurse instructs the employees that which is the first consideration in immediate care? 57) A client who sustained an inhalation injury arrives in the emergency department. On initial assessment, the nurse notes that the client is very confused and combative. The nurse determines that the client is most likely experiencing which condition? 58) A client is brought to the emergency department immediately after a smoke inhalation injury. The nurse initially prepares the client for which treatment? 59) The nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area from a fire. Which assessment finding would indicate that the client sustained a respiratory injury as a result of the burn? 60) The nurse is performing an assessment on a client who sustained circumferential burns of both legs. Which assessment would be the initial priority in caring for this client? 61) The nurse is developing a plan of care for a client who sustained an inhalation burn injury. Which nursing intervention should the nurse include in the plan of care for this client? 62) The nurse has developed a nursing care plan for a client with a burn injury to implement during the emergent phase. Which priority intervention should the nurse include in the plan of care? 63) The nurse is developing a nursing care plan for a client with a circumferential burn injury of the right arm. What is the nurse's priority action? 64) Vasopressin is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse should prepare to administer this medication by which route? 65) Vasopressin therapy is prescribed for a client with a diagnosis of bleeding esophageal varices. The nurse is preparing to administer the medication to the client. Which essential item is needed during the administration of this medication? 66) The nurse is monitoring a client who required a Sengstaken-Blakemore tube because other measures for treating bleeding esophageal varices were unsuccessful. The client complains of severe pain of abrupt onset. Which nursing action is most appropriate? 67) A postpartum client who received an epidural analgesic after giving birth by cesarean section is lethargic and has a respiratory rate of 8 breaths per minute. The nurse should obtain which medication from the emergency cart after notifying the health care provider? 68) The nurse is reviewing the medical record of a client transferred to the medical unit from the critical care unit. The nurse notes that the client received intra-aortic balloon pump (IABP) therapy while in the critical care unit. The nurse suspects that the client received this therapy for which condition? 69) The nurse is providing care for a client who sustained burns over 30% of the body from a fire. On assessment, the nurse notes that the client is edematous in both burned and unburned body areas. The client's wife asks why her husband "looks so swollen." What is the nurse's best response? 70) The emergency department nurse is monitoring a client who received treatment for a severe asthma attack. The nurse determines that the client's respiratory status has worsened if which is noted on assessment? 71) The nurse is performing an assessment on a client who was admitted with a diagnosis of carbon monoxide poisoning. Which assessment performed by the nurse would primarily elicit data related to a deterioration of the client's condition? 72) The nurse is reviewing the laboratory test results for a client admitted to the burn unit 3 hours after an explosion that occurred at a worksite. The client has a severe burn injury that covers 35% of the total body surface area (TBSA). The nurse is most likely to note which finding on the laboratory report? 73) The nurse is caring for a client who sustained a thermal burn caused by the inhalation of steam 24 hours ago. The nurse determines that the priority nursing action is to assess which item? 74) A client with depression receiving phenelzine sulfate suddenly complains of a severe headache and neck stiffness and soreness and then begins to vomit. The nurse takes the client's blood pressure and notes that it is 210/102 mm Hg. On the basis of the findings, the nurse should obtain which medication from the emergency drawer of the medication cart? 75) Acetylcysteine is prescribed for a client in the hospital emergency department after diagnosis of acetaminophen overdose. The nurse prepares to administer the medication using which procedure? 76) A pregnant client being admitted to the labor room tells the nurse that she felt a large gush of fluid before arriving at the hospital. The nurse performs an assessment on the client and notes that the fetal heart rate is 90 beats/minute and that the umbilical cord is protruding from the vagina. What is the appropriate nursing action? 77) The nurse receives a telephone call from a neighbor, who states that her 3-year-old child was found sitting on the kitchen floor with an empty bottle of liquid furniture polish. The mother of the child tells the nurse that the bottle was half full, that the child's breath smells like the polish, and that spilled polish is present on the front of the child's shirt. What should the nurse tell the mother to do first? 78) The nurse is caring for a client who sustained multiple fractures in a motor vehicle crash 12 hours earlier. The client now exhibits severe dyspnea, tachycardia, and mental confusion, and the nurse suspects fat embolism. Which is the initial nursing action? 79) The home health nurse is visiting an older client whose family has gone out for the day. During the visit, the client experiences chest pain that is unrelieved by sublingual nitroglycerin tablets given by the nurse. Which action by the nurse would be appropriate at this time? 80) The client who has experienced a myocardial infarction (MI) is recovering from cardiogenic shock. The nurse knows that which observation of the client's clinical condition is most favorable? 81) A client in cardiogenic shock has a pulmonary artery catheter (Swan-Ganz type) placed. The nurse would interpret which cardiac output (CO) and pulmonary capillary wedge pressure (PCWP) readings as indicating that the client is most unstable? 82) A client in cardiogenic shock had an intra-aortic balloon pump inserted 24 hours earlier via the left femoral approach. The nurse notes that the client's left foot is cool and mottled and the left pedal pulse is weak. Which action should the nurse take? 83) The nurse is caring for a client with a chest tube drainage system. While the client is being assisted to sit up in bed in preparation for ambulation, the chest tube accidentally disconnects from the chest drainage system. Which is the initial nursing action? 84) The nurse is caring for a client with a chest tube drainage system. During repositioning of the client, the chest tube accidentally pulls out of the pleural cavity. Which is the initial nursing action?  . 85) The nurse reviewing the operative record for a client who has just undergone cardiac surgery notes that the client's cardiac output immediately after surgery was 3.6 L/min. Which intervention is appropriate based on the client's cardiac output reading? 86) The nurse has a prescription to administer acetylcysteine to a client admitted to the emergency department with acetaminophen overdose. Before giving this medication, what is the nurse's best action? 87) A client with a history of gastric ulcer complains of a sudden, sharp, severe pain in the midepigastric area, which then spreads over the entire abdomen. The client's abdomen is rigid and boardlike on palpation, and the client obtains most comfort from lying in the knee-chest position. The nurse suspects which condition and should perform which action? 88) A postoperative client receives a dose of naloxone hydrochloride for respiratory depression shortly after transfer to the nursing unit from the postanesthesia care unit. After administration of the medication, the nurse should assess the client for which change? 89) A new nursing graduate is caring for a client who is attached to a cardiac monitor. While assisting the client with bathing, the nurse observes the sudden development of ventricular tachycardia (VT), but the client remains alert and oriented and has a pulse. Which interventions would the nurse take? Select all that apply.  . 90) An emergency department nurse is caring for a child with suspected acute epiglottitis. Which nursing interventions apply in the care of this child? Select all that apply. 91) A client with a left arm fracture supported in a cast complains of loss of sensation in the left fingers. The nursing assessment identifies pallor in the distal portion of the arm, poor capillary refill, and a diminished left radial pulse. On the basis of these findings, the nurse would take which as a priority action? 92) The nurse is caring for a client who is receiving feedings by nasogastric tube. The client suddenly begins to vomit, and the nurse quickly repositions the client. The client is coughing and having difficulty breathing. What is the nurse's priority action? 93) A delivery room nurse is caring for a client in labor. The client tells the nurse that she feels that something is coming through the vagina. The nurse performs an assessment and notes the presence of the umbilical cord protruding from the vagina. The nurse should immediately place the client in which position? 94) The nurse witnesses an accident whereby a pedestrian is hit by an automobile. The nurse stops at the scene and assesses the victim. The nurse notes that the victim is responsive and has suffered trauma to the thorax resulting in a flail chest involving at least 3 ribs. What is the nurse's priority action for this victim? 95) The nurse is assessing a client hospitalized with acute pericarditis. The nurse monitors the client for cardiac tamponade, knowing that which signs are associated with this complication of pericarditis? Select all that apply. 96) A client has frequent runs of ventricular tachycardia. The health care provider has prescribed flecainide. What is the best nursing action related to the effects of this medication while the client is hospitalized? 97) A postpartum client with femoral thrombophlebitis has developed sudden shortness of breath and appears very anxious. What is the nurse's priority action for this client? 98) The child with croup is being discharged from the hospital. The nurse provides instructions to the mother and advises the mother to bring the child to the emergency department if which occurs? 99) The occupational health nurse is called to care for an employee who experienced a traumatic amputation of a finger. Which actions should the nurse take to provide emergency care and prepare the client for transport to the hospital? Select all that apply. 100) An emergency department nurse is caring for a conscious child who was brought to the emergency department after the ingestion of half a bottle of acetylsalicylic acid (aspirin). The nurse anticipates that which will be the initial treatment? 101) The nurse is providing care for a client with new onset of a dysrhythmia. The nurse anticipates which prescriptions from the health care provider? Select all that apply. Refer to Figure. View Figure 102) A depressed client is found unconscious on the floor in the dayroom of a health care facility. The nurse finds several empty bottles of a prescribed tricyclic antidepressant lying near the client. Which is the priority action of the nurse? 103) A client begins experiencing wheezing, anxiety, swelling, and hives after eating shellfish and is brought to the emergency department. Which immediate action should the nurse implement? 104) The nurse prepares to administer acetylcysteine to the client with an overdose of acetaminophen. What is the appropriate action when administering this antidote? 105) A client who has just suffered a large flail chest is experiencing severe pain and dyspnea. The client's central venous pressure (CVP) is rising, and the arterial blood pressure is falling. Which condition should the nurse interpret that the client is experiencing? 106) A client develops atrial fibrillation with a ventricular rate of 140 beats/minute and signs of decreased cardiac output. Which medication should the nurse anticipate administering first? 107) A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath and is visibly anxious. Which complication should the nurse immediately assess the client for? 108) A client with no history of respiratory disease is admitted to the hospital with respiratory failure. Which results on the arterial blood gas report that are consistent with this disorder should the nurse expect to note? 109) The nurse in the labor room is performing an initial assessment on a newborn. The infant is exhibiting mild to moderate respiratory distress, audible bowel sounds in the chest, and a scaphoid abdomen. The infant is responding poorly to bag and mask ventilation. The nurse plans for which actions in the care of this infant? Select all that apply. 110) A child is admitted to the hospital after being seen in the emergency department with complaints of right lower quadrant abdominal pain, nausea and vomiting, fever, and chills. The health care provider (HCP) suspects appendicitis. Which assessment finding should the nurse immediately report to the HCP? 111) The mother of a 3-year-old boy calls the emergency department and states that she found an empty bottle of acetaminophen on the floor. She states that she thinks her child ingested all of the medication. What is the priority question for the nurse to ask the mother? 112) A 5-year-old boy is brought by his mother to the emergency department after ingesting a bottle of acetylsalicylic acid. Which procedure should be initially instituted with this child? 113) A mother brings her child to the emergency department. Based on the child's sitting position, drooling, and apparent respiratory distress, a diagnosis of epiglottitis is suspected. In anticipation of the health care provider's prescriptions, in which order of priority would the nurse implement the actions? Arrange the actions in the order that they should be performed. All options must be used. 114) The nurse is caring for a client who has overdosed on phenobarbital. The nurse anticipates which assessment finding with this client? 115) The nurse is caring for a client who has overdosed on amphetamines. The nurse anticipates noting which assessment finding in this client? 116) A client experiencing cocaine toxicity is brought to the emergency department. The nurse should prepare to take which initial action? 117) Which readings obtained from a client's pulmonary artery catheter suggest that the client is in left-sided heart failure? 118) When creating a mechanically ventilated client's plan of care for prevention of ventilator-associated pneumonia (VAP), the nurse should include which measures in the plan? Select all that apply. 119) Which step should occur first when using an automated external defibrillator (AED)? 120) Which should the nurse do when setting up an arterial line? 121) Which interventions would be included in the care of a client with a head injury and a subarachnoid bolt? Select all that apply. 122) Which clinical manifestations of a tension pneumothorax should be of immediate concern to the nurse? Select all that apply. 123) A client's arterial blood gas results reveal a PaO2 of 55 mm Hg. The client's admitting diagnosis is acute respiratory failure secondary to community-acquired pneumonia. What is the nurse's best action? 124) A client is admitted to the hospital for an acute episode of angina pectoris. Which parameter is the priority for the nurse to monitor? 125) The nurse is caring for a client in the emergency department who has sustained a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing that this sequence is compatible with which most likely condition? 126) The family of a client with a spinal cord injury rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic with a flushed face and neck and is complaining of a severe headache. The pulse rate is 40 beats/minute, and the blood pressure is 230/100 mm Hg. The nurse acts quickly, suspecting that the client is experiencing which condition? 127) A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, the nurse takes the following actions. Arrange the actions in the order they should be performed. All options must be used. 128) A client is admitted to the hospital with a diagnosis of neurogenic shock after a traumatic motor vehicle collision. Which manifestation best characterizes this diagnosis? 129) The nurse is performing a vaginal assessment of a pregnant woman who is in labor. The nurse notes that the umbilical cord is protruding from the vagina. The nurse would immediately take which action? 130) A client in the postpartum unit complains of sudden, sharp chest pain. The client is tachycardic, and the respiratory rate is increased. The health care provider diagnoses a pulmonary embolism. Which actions should the nurse plan to take? Select all that apply.  . 131) A client with angina pectoris is experiencing chest pain that radiates down the left arm. The nurse administers a sublingual nitroglycerin tablet to the client. The client's pain is unrelieved, and the nurse determines that the client needs another nitroglycerin tablet. Which vital sign is the most important for the nurse to check before administering the medication? 132) A client whose cardiac rhythm was normal sinus rhythm suddenly exhibits a different rhythm on the monitor. The nurse should take which action? Refer to Figure. View Figure 133) The nurse is assisting in the care of a client who is being seen in the clinic with a suspected acetaminophen overdose. What is the nurse's priority of care? 134) A client who suffered carbon monoxide poisoning from working on an automobile in a closed garage has a carbon monoxide level of 15%. The nurse should anticipate observing which sign or symptom? 135) A client presents to the urgent care center with complaints of abdominal pain and vomits bright red blood. Which is the 136) The nurse is admitting a young child who arrived from the emergency department after treatment for acetaminophen overdose. After administering the antidote, the nurse should reassess the child, including which priority laboratory value? 137) The nurse is monitoring a child who is receiving ethylenediaminetetraacetic acid (EDTA) with BAL (British anti-Lewisite) for the treatment of lead poisoning. The nurse reviews the laboratory results for the child during treatment with this medication and is particularly concerned with monitoring which laboratory test result? 138) The nurse is caring for a child who was burned in a house fire. The nurse develops a plan of care for monitoring the child during the treatment for burn shock. The nurse identifies which assessment as providing the most accurate guide to determine the adequacy of fluid resuscitation? 139) A 2-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering more than 40% of the body. The burns are both partial- and full-thickness burns. The nurse is asked to prepare for the arrival of the child and gathers supplies, anticipating that which treatment will be prescribed initially? 140) A mother brings her child to the emergency department. Based on the child's sitting position, drooling, and apparent respiratory distress, a diagnosis of epiglottitis is suspected. The nurse should plan for which priority intervention? 141) A client had a 1000-mL bag of 5% dextrose in 0.9% sodium chloride hung at 1500. The nurse, making rounds at 1545, finds that the client is apprehensive, complaining of a pounding headache, is dyspneic with chills, and has an increased pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which action first? 142) When performing a surgical dressing change of a client's abdominal dressing, the nurse notes an increase in the amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. What should the nurse do 143) The nurse is caring for a client with a chest tube who accidentally disconnects the tube from the drainage system when trying to get out of bed. The nurse immerses the end of the tube in sterile water. What immediate action should the nurse take? 144) Which client situation is most appropriate for the nurse to consult with the Rapid Response Team (RRT)? 145) A client who attempted suicide by hanging is brought to the emergency department by emergency medical services. Which is the immediate nursing action? 146) The nurse has a prescription to hang a 1000-mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of potassium chloride and needs to add the medication to the IV bag. The nurse should plan to take which action immediately after injecting the potassium chloride into the port of the IV bag? 147) The nurse notes that the client's intravenous (IV) site is cool, pale, and swollen and that the solution is not infusing. What is the nurse's priority action? 148) The nurse is inserting an intravenous (IV) line into a client's vein. After the initial stick, the nurse would continue to advance the catheter in which situation? 149) The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking appropriate steps to care for the client, the nurse should document in the medical record that the client experienced which condition? 150) The nurse is preparing a continuous intravenous (IV) infusion at the medication cart. As the nurse goes to insert the spike end of the IV tubing into the IV bag, the tubing drops and the spike end hits the top of the medication cart. The nurse should take which action? 151) A health care provider has written a prescription to discontinue an intravenous (IV) line. The nurse should obtain which item from the unit supply area for applying pressure to the site after removing the IV catheter? 152) A client complains of pain at the site of an intravenous (IV) infusion. The nurse assesses the site and determines that phlebitis has developed. The nurse should take which actions in the care of this client? Select all that apply. 153) A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which intravenous (IV) solution will most likely be prescribed? 154) The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instruction if the client makes which statement? 155) A client has just undergone insertion of a central venous catheter at the bedside. The nurse would be sure to check which results before initiating the flow rate of the client's intravenous (IV) solution at 100 mL/hour?  Portable chest x-ray film 156) A client with the recent diagnosis of myocardial infarction and impaired renal function is recuperating on the cardiac step-down unit. The client's blood pressure has ::::::::::::::::::::::::::::::::::::::::CONTENT CONTINUED IN THE ATTACHMENT::::::::::::::::::::::::::::::::::::::::::::::::::: [Show More]

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 *NURSING> NCLEX > Saunders Comprehensive Review for Nclex FIVE-with 100% verified answers- 2022 (All)

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Saunders Comprehensive Review for Nclex FIVE-with 100% verified answers- 2022

1)A child with an autism spectrum disorder (ASD) is being admitted to the hospital for diagnostic tests. Which room assignment is the most appropriate for the child? ✓Private room 2)The labor and de...

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 *NURSING> NCLEX > SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FIVE (All)

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SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX FIVE

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