NURSING Med Surg 2 SAUNDERS COMPREHENSIVE REVIEW FOR NCLEX QUESTIONS WITH ANSWERS 100%CORR, Exams of Nursing

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1) The nurse is providing discharge instructions to a Chinese

American client regarding prescribed dietary modifications. During

the teaching session, the client continuously turns away from the

nurse. The nurse should implement

which best action?

✓ Answers-Continue with the instructions,

verifying client understanding.

2) 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.

3) 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

4) 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."

5) 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?

✓ Answers-Reflecting a cultural value

6) When communicating with a client who speaks a different

language, which best practice should the nurse implement?

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✓ Arrange for an interpreter to translate.

7) The nurse educator is providing in-service education to the

nursing staff regarding transcultural nursing care; a staff

member asks the nurse educator to provide an example of the

concept of acculturation. The nurse educator should make

which most appropriate response?

✓ Answers-"A person who moves from China to

the United States (U.S.) and learns about and adapts ato

the culture in the U.S."

8. An Asin American client is experiencing a

fever. The nurse plans care so that the client can self-treat the disorder

using which method?

✓ Foods considered to be yin

9. Which meal tray should the nurse deliver to a

client of Orthodox Judaism faith who follows a kosher diet?

✓ Sweet and sour chicken with rice and vegetables,

mixed fruit, juice.

10. Which is the best nursing intervention regarding complementary and

alternative medicine?

✓ Educating the client about therapies that he or she

is using or is interested in using

11)An antihypertensive medication has been prescribed for a client with

hypertension. The client tells the clinic nurse that he would like to take

an herbal substance to help lower his blood pressure. The nurse should

take which action?

✓ Encourage the client to discuss the use of an herbal

substance with the health care provider (HCP).

12. The nurse educator asks a student to list

the 5 main categories of complementary and alternative medicine

(CAM), developed by the National Center for Complementary and

Alternative Medicine. Which statement, if

made by the nursing student, indicates a need for further teaching

regarding CAM categories?

✓ "Magnetic therapy and massage

therapy are a focus of CAM."

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13. The nurse hears a client calling out for help, hurries down the

hallway to the client's room, and finds the client lying on the floor. The

nurse performs an assessment, assists the client back to bed, notifies

the health care provider of the incident, and completes an incident

report. Which statement should the nurse document on the incident

report?

✓ The client was found lying on the floor.

14. A client is brought to the emergency department by emergency

medical services (EMS) after being hit by a car. The name of the client

is unknown, and the client has sustained a severe head injury and

multiple fractures and is unconscious. An emergency craniotomy is

required. Regarding informed consent for the surgical

procedure, which is the best action?

✓ Transport the victim to the operating room for surgery.

15) The nurse has just assisted a client back to bed after a fall. The

nurse and health care provider have assessed the client and have

determined that the client is not injured. After completing the incident

report, the nurse should implement which action next?

✓ Reassess the client.

16. The nurse arrives at work and is told to report (float) to the intensive

care unit (ICU) for the day because the ICU is understaffed and needs

additional nurses to care for the clients. The nurse has never worked in

the ICU. The nurse should take

which best action?

✓ Clarify with the team leader to make a safe ICU client assignment.

17. The nurse who works on the night shift enters the medication room

and finds a co-worker with a tourniquet wrapped around the upper arm.

The co-worker is about to insert a needle, attached to a syringe

containing a clear liquid, into the antecubital area. Which is the most

appropriate action by the nurse?

✓ Call the nursing supervisor.

18. A hospitalized client tells the nurse that an instructional

directive is being prepared and that the lawyer will be bringing the

document to the hospital today for witness signatures. The client asks the

nurse for assistance in obtaining a

witness to the will. Which is the most appropriate response to the client?

✓ "I will call the nursing supervisor to seek assistance

regarding your request."

18. The nurse has made an error in a narrative documentation of an

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assessment finding on a client and obtains the client's record to correct the

error. The nurse should take which actions to correct the error? Select all that apply.

✓ Document the correct information and end with the nurse's

signature and title.

✓ Draw 1 line through the error, initialing and dating it.

19) Which identifies accurate nursing documentation notations? Select all that apply.

✓ 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.

20. A nursing instructor delivers a lecture to nursing students regarding

the issue of client's rights and asks a nursing student to identify a situation

that represents an example of invasion of client privacy. Which situation, if

identified by the student, indicates an understanding of a violation of this

client right?

✓ Observing care provided to the client without the client's permission

21. Nursing staff members are sitting in the lounge taking their morning

break. An unlicensed assistive personnel (UAP) tells the group that she

thinks that the unit secretary has acquired immunodeficiency syndrome

(AIDS) and proceeds to tell the nursing staff that the secretary probably

contracted the disease from her husband, who is supposedly a drug addict.

The registered nurse should inform the UAP that making this accusation has

violated which legal tort?

✓ Slander

22. An 87-year-old woman is brought to the emergency department for

treatment of a fractured arm. On physical assessment, the nurse notes old

and new ecchymotic areas on the client's chest and legs and asks the

client how the bruises were sustained. The client, although reluctant, tells

the nurse in confidence that her son frequently hits her if supper is not

prepared on time when he arrives home from work. Which is the most

appropriate nursing response?

✓ "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."

23. The nurse calls the heath care provider (HCP) regarding a new

medication prescription because the dosage prescribed is higher than the

recommended dosage. The nurse is unable to locate the HCP, and the

medication is due to be administered. Which action should the nurse take?

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✓ Contact the nursing supervisor.

24. The nurse employed in a hospital is waiting to receive a report from

the laboratory via the facsimile (fax) machine. The fax machine activates

and the nurse expects the report, but instead receives a sexually oriented

photograph. Which is the most appropriate initial nursing action?

✓ Call the nursing supervisor and report the incident.

25) The nurse is assigned to care for four clients. In planning client rounds, which client should the nurse assess first?

26. The nurse employed in an emergency department is assigned to triage clients

coming to the emergency department for treatment on the evening shift. The nurse should assign priority to which client?

27. A nursing graduate is attending an agency orientation regarding the

nursing model of practice implemented in the health care facility. The nurse

is told that the nursing model is a team nursing approach. The nurse

determines that which scenario is characteristic of the team-based model of

nursing practice?

28) The nurse has received the assignment for the day shift. After making

initial rounds and checking all of the assigned clients, which client should

the nurse plan to care for first?

29. The nurse is giving a bed bath to an assigned client when an unlicensed

assistive personnel (UAP) enters the client's room and tells the nurse that another assigned client is in pain and needs pain medication. Which is the most appropriate nursing action?

30. The nurse manager has implemented a change in the method of

the nursing delivery system from functional to team nursing. An

unlicensed assistive personnel (UAP) is resistant to the change and is not

taking an active part in facilitating the process of change. Which is the

best approach in dealing with the UAP?

31. The registered nurse is planning the client assignments for the day. Which is the most appropriate assignment for an unlicensed

assistive personnel (UAP)?

32. The nurse manager is discussing the facility protocol in the event of a tornado

with the staff. Which instructions should the nurse manager include in the discussion? Select all that apply.

33. The nurse employed in a long-term care facility is planning

assignments for the clients on a nursing unit. The nurse needs to assign four

clients and has a licensed practical (vocational) nurse and 3 unlicensed

assistive personnel (UAPs) on a nursing

team. Which client would the nurse most appropriately assign to the

licensed practical (vocational) nurse?

34) The charge nurse is planning the assignment for the day. Which factors should the nurse remain mindful of when planning the assignment? Select all that apply.

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35. The nurse is caring for a client with heart failure. On assessment, the

nurse notes that the client is dyspneic, and crackles are audible on

auscultation. What additional manifestations would the nurse expect to

note in this client if excess fluid volume is present?

36. The nurse is preparing to care for a client with a potassium deficit. The

nurse reviews the client's record and determines that the client is at risk for

developing the potassium deficit because of which situation?

37. The nurse reviews a client's electrolyte laboratory report and notes that the

potassium level is 2.5 mEq/L (2.5 mmol/L). Which patterns should the nurse watch for on the electrocardiogram (ECG) as a result of the laboratory value? Select all that apply.

38. Potassium chloride intravenously is prescribed for a client with hypokalemia.

Which actions should the nurse take to plan for preparation and administration of the potassium? Select all that apply.

39) The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? Select all that apply.

40. The nurse is reviewing laboratory results and notes that a client's

serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum

sodium level to the health care provider (HCP) and the HCP prescribes

dietary instructions based on

the sodium level. Which acceptable food items does the nurse instruct the client to consume? Select all that apply.

41. The nurse is assessing a client with a suspected diagnosis of

hypocalcemia. Which clinical manifestation would the nurse expect to

note in the client?

42) The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the electrocardiogram as a result of the

laboratory value? Select all that apply.

43. The nurse reviews the electrolyte results of an assigned client and notes that

the potassium level is 5.7 mEq/L (5.7 mmol/L). Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? Select all that apply.

44. Which client is at risk for the development of a sodium level at 130

mEq/L (130 mmol/L)?

45. The nurse is caring for a client with heart failure who is receiving high

doses of a diuretic. On assessment, the nurse notes that the client has flat

neck veins, generalized muscle weakness, and diminished deep tendon

reflexes. The nurse suspects hyponatremia. What additional signs would the

nurse expect to note in a client with hyponatremia?

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46. The nurse reviews a client's laboratory report and notes that the

client's serum phosphorus (phosphate) level is 1.8 mg/dL (0.45 mmol/L).

Which condition most likely caused this serum phosphorus level?

47. The nurse is reading a health care provider's (HCP's) progress

notes in the client's record and reads that the HCP has documented

"insensible fluid loss of approximately 800 mL daily." The nurse makes a

notation that insensible fluid loss occurs through which type of excretion?

48. The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most

likely at risk for a fluid volume deficit?

49. The nurse caring for a client who has been receiving intravenous (IV)

diuretics suspects that the client is experiencing a fluid volume deficit.

Which assessment finding would the nurse note in a client with this

condition?

50. On review of the clients' medical records, the nurse determines

that which client is at risk for fluid volume excess?

51. Which client is at risk for the development of a potassium level of

5.5mEq/L (5.5 mmol/L)?

52. 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

53. 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

54. 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

55. The nurse is caring for a client having respiratory distress related

to an anxiety attack. Recent arterial blood gas values are pH = 7.53, Pao 2

= 72 mm Hg (72 mm Hg), Paco 2 = 32 mmHg (32 mm Hg), and HCO – = 28

mEq/L (28 mmol/L). Which (^) conclusion about the client should the nurse

make?

✓ The client is probably hyperventilating.

56. The nurse is caring for a client with diabetic ketoacidosis and documents that

the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? Select all that apply.

✓ Respirations that are increased in rate

✓ Respirations that are abnormally deep

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57)A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Paco 2 is 90 mm Hg (90 mm Hg), and HCO 3

is 22 (^) mEq/L (22 mmol/L). The nurse interprets the results as indicating which condition? ✓ Respiratory acidosis without compensation

58. The nurse notes that a client's arterial blood gas (ABG) results reveal a pH of 7.50 and a Paco 2 of 30 mm Hg (30 mm Hg). The nurse monitors the client for which (^) clinical manifestations associated with these ABG results? Select all that apply. ✓ Nausea ✓ Confusion ✓ Tachycardia ✓ Lightheadedness
59. The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings? ✓ pH^ 7.25,^ Paco 2 50 mm^ Hg^ (50^ mm^ Hg)
60. 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)
61. The nurse is caring for a client with several broken ribs. The client is t likely to experience what type of acid-base imbalance? ✓ Respiratory acidosis from inadequate ventilation
62. 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
63. 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."
64. 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)
65. 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

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66. A client is receiving a continuous intravenous infusion of heparin

sodium to treat deep vein thrombosis. The client's activated partial

thromboplastin time (aPTT) is 65 seconds. The nurse anticipates that which

action is needed?

A client with a history of cardiac disease is due for a morning dose of

furosemide. Which serum potassium level, if noted in the client's laboratory

report, should be reported before administering the dose of furosemide?

✓ Leaving the rate of the heparin infusion as is

67. A client with a history of cardiac disease is due for a morning dose

of furosemide. Which serum potassium level, if noted in the client's

laboratory report, should be reported before administering the dose of

furosemide?

✓ 3.2 mEq/L (3.2 mmol/L)

68) 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 × 10

9 /L)

✓ Sodium 150 mEq/L (150 mmol/L)

✓ Segmented neutrophils 40% (0.40)

✓ White blood cells, 3000 mm

3 (3.0 × 10

9 /L)

69. The nurse is caring for a client who takes ibuprofen for pain. The nurse

is gathering information on the client's medication history, and determines it

is necessary to contact the health care provider (HCP) if the client is also

taking which

medications? Select all that apply.

✓ Warfarin

✓ Glimepiride

✓ Amlodipine

70)A client with diabetes mellitus has a glycosylated hemoglobin A1c level of

9%. On the (^) basis of this test result, the nurse plans to teach the client about

the need for which measure?

✓ Preventing and recognizing hyperglycemia

71. The nurse is caring for a client with a diagnosis of cancer who is

immunosuppressed. The nurse would consider implementing neutropenic

precautions if the client's white blood cell count was which value?

✓ 2000 mm

3 (2.0 × 10

9 /L)

72. A client brought to the emergency department states that he has

accidentally been taking 2 times his prescribed dose of warfarin for the past

week. After noting that the client has no evidence of obvious bleeding, the

nurse plans to take which action?

✓ Draw a sample for prothrombin time (PT) and

international normalized ratio (INR).

73. The nurse is caring for a postoperative client who is receiving demand-

dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain

control. The nurse enters the client's room and finds the client drowsy and

records the following vital signs: temperature 97.2°F (36.2°C) orally, pulse 52

beats per minute, blood pressure 101/58^ mm^ Hg,^ respiratory^ rate^11 breaths

per minute, and SpO 2 of 93% on 3 liters of

oxygen via nasal cannula. Which action should the nurse take next?

✓ Attempt to arouse the client.

74. An adult female client has a hemoglobin level of 10.8 g/dL ( mmol/L). The nurse interprets that this result is most likely caused by which condition noted in the client's history?

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✓ Iron deficiency anemia

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75. A client with a history of gastrointestinal bleeding has a platelet

count of 300,000 mm

3 (300 × 10

9 /L). The nurse should take which

action after seeing the laboratory results?

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

76. The nurse is teaching a client who has iron deficiency anemia about

foods she should include in the diet. The nurse determines that the client

understands the dietary modifications if which items are selected from the

menu?

✓ Oranges and dark green leafy vegetables

77. The nurse is planning to teach a client with malabsorption syndrome about the

necessity of following a low-fat diet. The nurse develops a list of high-fat foods to avoid and should include which food items on the list? Select all that apply.

✓ Margarine

✓ Cream cheese

✓ Luncheon meats

78. 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

79. 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

80. 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

81. 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

82. 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

83. 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

84. 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

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85. 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

86. A client is being weaned from parenteral nutrition (PN) and is expected

to begin taking solid food today. The ongoing solution rate has been 100

mL/hour. The nurse anticipates that which prescription regarding the PN

solution will accompany the diet prescription?

✓ Decrease PN rate to 50 mL/hour.

87. The nurse is preparing to change the parenteral nutrition (PN) solution bag and

tubing. The client's central venous line is located in the right subclavian vein. The nurse asks the client to take which essential action during the tubing change?

✓ Take a deep breath, hold it, and bear down.

88. A client with parenteral nutrition (PN) infusing has disconnected the

tubing from the central line catheter. The nurse assesses the client and

suspects an air embolism. The nurse should immediately place the client in

which position? ✓ On the left side, with the head lower than the feet

89. Which nursing action is essential prior to initiating a new prescription for 500 mL of fat emulsion (lipids) to infuse at 50 mL/hour?

✓ Determine whether the client has an allergy to eggs.

90. The nurse monitors the client receiving parenteral nutrition (PN) for

complications of the therapy and should assess the client for which

manifestations of hyperglycemia?

✓ Weakness, thirst, and increased urine output

91. The nurse is changing the central line dressing of a client receiving

parenteral nutrition (PN) and notes that the catheter insertion site appears

reddened. The nurse should next assess which item?

✓ Client's temperature

92. The nurse is preparing to hang fat emulsion (lipids) and notes that fat

globules are visible at the top of the solution. The nurse should take which

action?

✓ Obtain a different bottle of solution.

93. A client receiving parenteral nutrition (PN) suddenly develops a fever.

The nurse notifies the health care provider (HCP), and the HCP initially

prescribes that the solution and tubing be changed. What should the nurse do

with the discontinued materials?

✓ Prepare to send them to the laboratory for culture.

94. A client has been discharged to home on parenteral nutrition (PN). With each visit, the home care nurse should assess which parameter most closely in monitoring this therapy?

✓ Temperature and weight

95) The nurse, caring for a group of adult clients on an acute care medical- surgical nursing unit, determines that which clients would be the most likely candidates for parenteral nutrition (PN)? Select all that apply.

✓ A client with extensive burns

✓ A client with cancer who is septic

✓ A client with severe exacerbation of Crohn's disease

✓ A client with persistent nausea and vomiting from chemotherapy

96. The nurse is preparing to hang the first bag of parenteral nutrition (PN) solution via the central line of an assigned client. The nurse should obtain which most essential piece of equipment before hanging the solution?

✓ Electronic infusion pump

97. The nurse is making initial rounds at the beginning of the shift and notes that

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the parenteral nutrition (PN) bag of an assigned client is empty. Which

solution should the nurse hang until another PN solution is mixed and

delivered to the nursing unit?

✓ 10% dextrose in water

98. The nurse is monitoring the status of a client's fat emulsion (lipid)

infusion and notes that the infusion is 1 hour behind. Which action should the

nurse take?

✓ Ensure that the fat emulsion infusion rate is infusing

at the prescribed rate

99. A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The nurse should next assess the client for the presence of which condition?

✓ Crackles on auscultation of the lungs

100. The nurse is caring for a restless client

who is beginning nutritional therapy with parenteral nutrition (PN). The nurse

should plan to ensure that which action is taken to prevent the client from

sustaining injury?

✓ Secure all connections in the PN system.

101. A client receiving parenteral nutrition

(PN) complains of a headache. The nurse notes that the client has an

increased blood pressure, bounding pulse, jugular vein distention, and

crackles bilaterally. The nurse determines that the client is experiencing

which complication of PN therapy?

✓ Hypervolemia

102. 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 complaining of a pounding headache and is

dyspneic, experiencing chills, and apprehensive, with an increased pulse rate.

The intravenous (IV) bag has 400 mL

remaining. The nurse should take which action first?

✓ Slow the IV infusion.

103) The nurse has a prescription to hang a

1000- mL intravenous (IV) bag of 5% dextrose in water with 20 mEq of

potassium chloride. The nurse also needs to hang an IV infusion of

piperacillin/tazobactam. The client has one IV site. The nurse should plan to

take which action first?

✓ Check compatibility of the medication and IV fluids.

104. The nurse is completing a time tape for

a 1000- mL intravenous (IV) bag that is scheduled to infuse over 8 hours.

The nurse has just placed the 1100 marking at the 500-mL level. The nurse

would place the mark for 1200 at

which numerical level (mL) on the time tape? Fill in the blank.

✓ 375ml

105. The nurse is making initial rounds on the

nursing unit to assess the condition of assigned clients. Which assessment findings are consistent with infiltration? Select all that apply.

✓ Pallor and coolness

✓ Numbness and pain

✓ Edema and blanched skin

106. 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?

✓ Blood return shows in the backflash chamber of the catheter.

107. The nurse is assessing a client's

peripheral intravenous (IV) site after completion of a vancomycin infusion and

SAUNDERS NURSING Med Surg 2 REVIEW NCLEX QUESTIONS

WITH ANSWERS LATEST UPDATES 2022/2023 RATED A+

notes that the area is reddened, warm, painful, and slightly edematous

proximal to the insertion point of the IV

SAUNDERS NURSING Med Surg 2 REVIEW NCLEX QUESTIONS

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catheter. At this time, which action by the nurse is best?

✓ Remove the IV site and restart at another site.

108. 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?

✓ Obtain new IV tubing

109. 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?

✓ Sterile 2 × 2 gauze

110. A client rings the call light and 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.

✓ Remove the IV catheter at that site.

✓ Apply warm moist packs to the site.

✓ Notify the health care provider (HCP).

✓ Document the occurrence, actions taken, and the

client's response.

111. 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 for this client?

✓ 5% dextrose in lactated Ringer's solution

112. he 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 instructions if the client made which statement?

✓ "I need to restrict my activity while this catheter is in place."

113. A client has just undergone insertion of a

central venous catheter at the bedside under ultrasound. 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?

✓ Chest radiology results

114. Intravenous (IV) fluids have been infusing

at 100 mL/hour via a central line catheter in the right internal jugular for

approximately 24 hours to increase urine output and maintain the client's blood

pressure. Upon entering the client's room, the nurse notes that the client is

breathing rapidly and coughing. For which additional signs of a complication

should the nurse assess based on the previously known data?

✓ Crackles in the lungs

115. Packed red blood cells have been

prescribed for a female client with a hemoglobin level of 7.6 g/dL (76 mmol/L)

and a hematocrit level of 30% (0.30). The nurse takes the client's temperature

before hanging the blood transfusion and records 100.6°F (38.1°C) orally.

Which action should the nurse take?

✓ Delay hanging the blood and notify the health care

provider (HCP).

116. he nurse has received a prescription to

SAUNDERS NURSING Med Surg 2 REVIEW NCLEX QUESTIONS

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SAUNDERS NURSING Med Surg 2 REVIEW NCLEX QUESTIONS

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transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which initial question?

✓ "Have you ever had a transfusion before?"

117. A client receiving a transfusion of

packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is

90/50 mm Hg from a baseline of 125/78 mm Hg. The client's temperature is

100.8°F (38.2°C) orally from a baseline of 99.2°F (37.3°C) orally. The nurse

determines that the client may be experiencing which complication of a blood

transfusion?

✓ Septicemia

118. The nurse determines that a client is

having a transfusion reaction. After the nurse stops the transfusion, which

action should be

taken next?

✓ Run normal saline at a keep-vein-open rate.

119) The nurse has just received a unit of

packed red blood cells from the blood bank for transfusion to an assigned

client. The nurse is careful to select tubing especially made for blood products,

knowing that this tubing is manufactured with which item? Click on the

image to indicate your answer.

120. A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which finding?

✓ Decreased oozing of blood from puncture sites and gums

A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which

finding?

✓ Decreased oozing of blood from puncture sites and gums

The nurse has obtained a unit of blood from the blood bank and has checked the blood

bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which priority item?

✓ Vital signs

The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. What action should the nurse take next?

✓ Check to be sure that consent for the transfusion has been signed.

Following infusion of a unit of packed red blood cells, the client has developed new

onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement first?

✓

The nurse, listening to the morning report, learns that an assigned

client received a unit of granulocytes the previous evening. The

nurse makes a

note to assess the results of which daily serum laboratory studies to assess the effectiveness of the transfusion?

✓ White blood cell count

A client is brought to the emergency department having experienced

SAUNDERS NURSING Med Surg 2 REVIEW NCLEX QUESTIONS

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blood loss related to an arterial laceration. Which blood component

should the nurse expect the health care provider to prescribe?

✓ Fresh-frozen plasma

The nurse who is about to begin a blood transfusion knows that

blood cells start to deteriorate after a certain period of time. The

nurse takes which actions in order to prevent a complication of the

blood transfusion as it relates to deterioration of blood cells?

Select all that apply.

✓ Checks the expiration date

✓ Hangs the blood within the specified time frame per agency policy

A client requiring surgery is anxious about the possible need for a

blood transfusion during or after the procedure. The nurse

suggests to the client to take which actions to reduce the risk of

possible transfusion

complications? Select all that apply.

✓ Ask a family member to donate blood ahead of

time.

✓ Give an autologous blood donation before the surgery.

A client with severe blood loss resulting from multiple trauma

requires rapid transfusion of several units of blood. The nurse asks

another health team member to obtain which device for use

during the transfusion procedure to help reduce the risk of cardiac

dysrhythmias?

✓ Blood-warming device

A client has a prescription to receive a unit of packed red blood

cells. The nurse should obtain which intravenous (IV) solution

from the IV storage area to hang with the blood product at the

client's bedside?

✓ 0.9% sodium chloride

The nurse is caring for a client who is receiving a blood

transfusion and is complaining of a cough. The nurse checks the

client's vital signs, which include temperature of 97.2°F (36.2°C),

pulse of 108 beats per minute, blood pressure of 152/76 mm Hg,

respiratory rate of 24 breaths per minute, and an oxygen

saturation level of 95% on room air. The client

denies pain at this time. Based on this information, what initial

action should the nurse take?

✓ Compare current data to baseline data.

A Spanish-speaking client arrives at the triage desk in the emergency

department and states to the nurse, "No speak English, need interpreter." Which is the best action for the nurse to take?

✓ Page an interpreter from the hospital's interpreter services.

The nurse is performing a neurological assessment on a client

SAUNDERS NURSING Med Surg 2 REVIEW NCLEX QUESTIONS