SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX 5_2022/2023 | MED SURG SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX 5

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SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX 5 1000 questions and answers 170+ pages 1) A child with an autism spectrum disorder (ASD) is being admitted to the hospital for diagnostic tests. Which roo... m assignment is the most appropriate for the child? 2) The labor and delivery room nurse has just received reports on 4 clients. After reviewing the client data, the nurse should assess which client first? 3) The nurse has developed a teaching plan for a client with hypertension regarding the administration of prescribed medications. What is the initial nursing action? 4) A client with cancer is receiving intravenous morphine sulfate for pain. When writing the plan of care for this client, the nurse should include which action as the priority action? 5) The nurse is preparing to suction the airway of a client who has a tracheostomy tube and gathers the supplies needed for the procedure. In order of priority, which actions should the nurse take to perform this procedure? Arrange the actions in the order that they should be performed. All options must be used. 6) The nurse notes blanching, coolness, and edema at a client's peripheral intravenous (IV) site. Which nursing action is the priority? 7) A client has a prescription to begin an infusion of 1000 mL of 5% dextrose in lactated Ringer's solution. The client has an intravenous (IV) cannula inserted, and the nurse prepares the solution and IV tubing. Arrange the actions in the order that they should be performed. All options must be used. 8) The nurse is caring for 4 pediatric clients. After receiving reports from the night shift, which child should the nurse assess first? 9) The nurse is assigned to 4 clients on a postoperative surgical unit at a rural hospital. When prioritizing the care, the nurse recognizes that the highest priority is focused on which client? 10) The emergency department nurse is caring for a child with suspected epiglottitis and has ensured that the child has a patent airway. Which action is the next priority in the care of this child? 11) The nursing instructor asks the nursing student to identify the priorities of care for an assigned client. The nursing instructor determines that the nursing student understands the client's needs when which statement is made? 12) A hospitalized client with type 1 diabetes mellitus received Humulin N and Humulin R insulin 2 hours ago (at 7:30 a.m.). The client calls the nurse and reports that he is feeling hungry, shaky, and weak. The client ate breakfast at 8 a.m. and is due to eat lunch at noon. Arrange the actions that the nurse will take in the order that they should be performed. All options must be used. 13) An emergency department nurse is preparing to receive 4 clients as a result of a motor vehicle crash. Which victim should the nurse attend to first? 14) The nurse is assigned to care for 4 clients. Which client should the nurse assess first? 15) The nurse has received her client assignment for the day. Which client should the nurse care for first? 16) The nurse has received the client assignment for the day. Which client should the nurse care for first? 17) The nurse is the first responder at the scene of a 6-car crash on a highway. Which victim should the nurse attend to first? 18) The nurse in charge of a nursing unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply. 19) The nurse has received her client assignment for the day. Which client should the nurse check first? 20) The nurse is a responder at the scene of a building collapse. Which victim should the nurse care for first? 21) The nurse manager of a medical-surgical unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply. 22) The nurse is the first responder at the scene of an accident in which a tire blowout caused a bus to roll over several times. Which victim should the nurse attend to first? 23) The nurse in charge of a nursing unit is asked to select those hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Which clients can be safely discharged? Select all that apply. 24) The nurse has received her client assignment for the day. Which client should the nurse care for first? 25) During morning report, the day nurse is given information on the assigned clients. Which client should the nurse assess first? 26) The nurse determines that which client has the highest priority needs? 27) When planning care, which client should the nurse assess first? 28) The nurse assigned to 4 clients reviews client data at the beginning of the shift. To which information should the nurse give highest priority? 29) A home health care nurse is planning client visits and nursing activities for the day. The nurse begins the visits at 9 a.m. All clients live within a 5-mile radius. In order of priority, how the nurse should plan the assignments for the day? Arrange the actions in the order that they should be performed. All options must be used. 30) The nurse is monitoring a client receiving total parenteral nutrition (TPN). The client suddenly develops respiratory distress, dyspnea, and chest pain, and the nurse suspects air embolism. In order of priority, how should the nurse plan the actions to take? Arrange the actions in the order that they should be performed. All options must be used. 31) A unit of packed red blood cells has been prescribed for a client with low hemoglobin and hematocrit typing and crossmatching. The nurse receives a telephone call from the blood bank and is informed that the unit of blood is ready for administration. In order of priority, how should the nurse plan the actions to take? Arrange the actions in the order that they should be performed. All options must be used. 32) The nurse is monitoring a client in labor who is receiving oxytocin and notes that the client is experiencing hypertonic uterine contractions. In order of priority, how should the nurse plan the actions to take? Arrange the actions in the order that they should be performed. All options must be used. 33) After correctly completing the rights of medication administration, performing hand hygiene, and ensuring the correct position of the client, which steps should the nurse take to administer medication via a volume control container? Arrange the actions in the order that they should be performed. All options must be used. 34) The nurse from a medical unit is called to assist with care for clients coming into the hospital emergency department during an external disaster. Using principles of triage during a disaster, the nurse should attend to the client with which problem first? 35) The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first? 36) The nurse in charge of a nursing unit is asked to select the hospitalized clients who can be discharged so that hospital beds can be made available for victims of a community disaster. Select the clients who can be safely discharged. Select all that apply. 37) The nurse is the first responder at the scene of a train accident. Which victim should the nurse attend to first? 38) Which client should the emergency department triage nurse classify as emergent? 39) The nurse has performed a nonstress test on a pregnant client and is reviewing the fetal monitor strip. How should the nurse document this finding in the client's medical record? Refer to Figure. (Figure from McKinney et al. [2013], p. 310.)

View Figure 40) The nursing instructor asks the nursing student about the physiology related to the cessation of ovulation that occurs during pregnancy. Which response, if made by the student, indicates an understanding of this physiological process? Select all that apply. 41) The nurse encourages a pregnant client who is human immunodeficiency virus (HIV) positive to immediately report any early signs of vaginal discharge or perineal tenderness to the health care provider. The client asks the nurse about the importance of this action, and the nurse responds by making which statement to the client? 42) A pregnant client who is anemic tells the nurse that she is concerned about her infant's condition after delivery. Which nursing response would best support the client? 43) The client is being seen at 24 weeks' gestation at the prenatal clinic. At her last routine visit, the fundus was located at the umbilicus. Today, the fundus is measured and found to be 23 cm. How should the nurse interpret this finding? 44) The nurse is performing a prenatal assessment on a pregnant client. The nurse should plan to implement teaching related to risk for abruptio placentae if which information is obtained on assessment? 45) During a prenatal visit, the nurse is explaining dietary management to a client with preexisting diabetes mellitus. The nurse determines that teaching has been effective if the client makes which statement? 46) The nurse has provided home care instructions to a client with a history of cardiac disease who has just been told that she is pregnant. Which statement, if made by the client, indicates a need for further instruction? 47) The nurse assists a pregnant client with cardiac disease to identify resources to help her care for her 18-month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources primarily for which reason? 48) The nurse is instructing a pregnant client on measures to increase iron in the diet. The nurse should tell the client to consume which food that contains the highest source of dietary iron? 49) The nurse is reviewing a nutritional plan of care with a pregnant client and is identifying the food items highest in folic acid. The nurse determines that the client understands the foods that supply the highest amounts of folic acid if the client states that she will include which item in the daily diet? 50) A pregnant client who is at 30 weeks' gestation comes to the clinic for a routine visit, and the nurse performs an assessment on her. Which observations made by the nurse during the assessment indicates a need for further teaching? Select all that apply. 51) A pregnant client tells the nurse that she frequently has a backache, and the nurse provides instructions regarding measures that will assist in relieving the backache. Which statement by the client indicates a need for further instruction? 52) A nonstress test is prescribed for a pregnant client, and she asks the nurse about the procedure. How should the nurse respond? 53) The nurse is developing a plan of care for a pregnant client who is complaining of intermittent episodes of constipation. To help alleviate this problem, the nurse should instruct the client to take which measure? 54) A pregnant client in the prenatal clinic is scheduled for a biophysical profile (BPP). The client asks the nurse what this test involves. The nurse should make which appropriate response? 55)  The nurse is taking a nutritional history from a 16-year-old pregnant adolescent. Which statement, if made by the adolescent, should alert the nurse to a potential psychosocial problem? 56) The nurse is conducting a session about nutrition with a group of adolescents who are pregnant. Which measure is most appropriate to teach these adolescents? 57) The nurse is discussing nutrition with a pregnant client who has lactose intolerance. The nurse should instruct the client to supplement the dietary source of calcium by eating which food? 58) The nurse has provided instructions to a pregnant client who is preparing to take iron supplements. The nurse determines that the client understands the instructions if she states that she will take the supplements with which item? 59) A client arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. The client tells the nurse that a home pregnancy test was positive but that she began to have mild cramps and is now having moderate vaginal bleeding. On physical examination of the client, it is noted that she has a dilated cervix. Which statement, if made by the client, indicates that the client is interpreting the situation correctly? 60) The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data, if noted on the client's record, should alert the nurse that the client is at risk for a spontaneous abortion? - - - - - - - - - - - 980) A child diagnosed with scarlet fever is being cared for at home. The home health nurse performs an assessment on the child and checks for which clinical manifestations of this disease? Select all that apply. 981) A child with acquired immunodeficiency syndrome is hospitalized for the treatment of Pneumocystis jiroveci pneumonia. The child will be receiving nebulizer treatments at home when discharged. The nurse instructs the mother regarding the maintenance of the nebulizer equipment. What should the nurse tell the mother to do? 982) A 12-month-old child with human immunodeficiency virus infection is currently immunocompromised. The nurse determines that the immunization needs of this child include which action? 983) The nursing student is assigned to administer immunizations to children in a clinic. The student should question whether to administer immunizations to a child with which condition? 984) The nurse is providing anticipatory guidance to the mother of a 10-month-old child. The mother asks how soon her daughter will be able to receive the chickenpox (varicella) vaccine. What is the best nursing response? 985) A child is scheduled to receive immunizations. The child's mother reports to the nurse that the child has been receiving long-term immunosuppressive therapy. The nurse prepares the scheduled immunizations knowing that which vaccine is contraindicated? 986) A child is sent to the school nurse by the teacher. On assessment of the child the nurse notes the presence of a rash. The nurse suspects that the child has erythema infectiosum (fifth disease) based on which assessment finding? 987) An infant is brought to the clinic for his third diphtheria–tetanus toxoid–acellular pertussis vaccination (DTaP). The mother reports that the infant developed a 99.4°F (37.4°C) temperature after the last DTaP. Which action is most appropriate? 988) The nurse should expect to administer the first dose of the measles, mumps, and rubella (MMR) vaccine at which age? 989) A school-age child is seen in the health care provider's office for complaints of intense itching mostly at night. The health care provider makes a diagnosis of scabies and prescribes permethrin for treatment of the skin condition. Which at-home instruction should the nurse provide to the mother? 990) A child who is 4 years old is seen for a well-child checkup. He has been regularly receiving immunizations. Which immunizations should the child receive at this visit? Select all that apply. 991) A child seen in the clinic is found to have rubeola (measles), and the mother asks the nurse how to care for the child. The nurse should tell the mother to implement which action? 992) A child is seen in the health care clinic, and the nurse suspects the presence of pinworm infection (enterobiasis). The nurse instructs the mother as to how to obtain a cellophane tape rectal specimen. Which statement by the mother indicates an understanding of the correct procedure to obtain the specimen? 993) An adolescent is seen in the health care clinic with complaints of chronic fatigue. On physical examination, the nurse notes swollen lymph nodes, and laboratory test results indicate the presence of Epstein-Barr virus (mononucleosis). The nurse provides instruction regarding care of the adolescent. Which statement made by the mother indicates an understanding of the care measures? 994) The nurse is caring for a hospitalized child with a diagnosis of measles (rubeola). In preparing to care for the child, which supplies should the nurse bring to the child's room to prevent transmission of the virus? 995) The nurse is caring for a child with a diagnosis of roseola. The nurse provides instructions to the mother regarding prevention of the transmission to siblings and other household members. Which instruction should the nurse provide? 996) A child hospitalized with pertussis is in the convalescent stage, and the nurse is preparing the child for discharge. The nurse has provided instructions to the parents for home care of the child. Which statement by a parent indicates a need for further teaching? 997) A child is seen in a health care clinic, and a diagnosis of chickenpox is confirmed. The mother expresses concern for two other children at home and asks the nurse if the child is infectious to the other children. Which response by the nurse is most appropriate? 998) The nurse is developing a plan of care for a 10-year-old girl with an exacerbation of eczema. Which problem should be addressed in the care for this child? 999) The nurse is providing a yearly summer educational session to parents in a local community. The topic of the session is prevention and treatment measures for poison ivy. The nurse instructs the parents that if the child comes into contact with poison ivy to take which action? 1000) A 2-year-old child is admitted to a hospital burn unit with partial- and full-thickness burns involving 35% of body surface area. After admission assessment and review of the health care provider's prescriptions, the priority nursing intervention should focus on which action? [Show More]

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