SAUNDERS/NCLEX/ASSESSMENT EXAM

Question 1

The signs and symptoms of air embolism

Answer 1

The signs and symptoms of air embolism include chest pain, dyspnea, hypoxia, anxiety, tachycardia, and hypotension. The nurse also may hear a loud churning sound over the pericardium on auscultation of the client’s chest.

Question 2

The signs and symptoms of sepsis

Answer 2

The signs and symptoms of sepsis include fever, chills, and general malaise. Fluid overload causes increased intravascular volume, which increases the blood pressure and the pulse rate as the heart tries to pump the extra fluid volume.

Question 3

Phlebitis

Infiltration

Thrombosis

Question 4

A nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. The nurse immediately applies sterile gauze over the chest tube insertion site. Which is the nurse’s next action?

Answer 4

CALL HCP

NO TRENDELBURG

Question 5

A nurse reviews the medication history of a client and notes that the client is taking leflunomide (Arava). During assessment of the client, the nurse should ask which question to determine theeffectiveness of this medication?

Answer 5

Leflunomide is an immunomodulatory agent and has an anti-inflammatory action. The medication provides symptomatic relief of rheumatoid arthritis. Diarrhea can occur as a side effect of the medication.

Question 6

A nulliparous woman asks the nurse when she will begin to feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately how many weeks of gestation?

Answer 6

18 WEEKS

The first recognition of fetal movements, or feeling life, by the multiparous woman may occur as early as 14 to 16 weeks’ gestation. The nulliparous woman may not notice these sensations until the 18 weeks’ gestation or later. The first recognition of fetal movement is called quickening.

Question 7

A nurse is assessing a woman in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which finding would the nurse expect to note if abruptio placentae is present?

Answer 7

Classic signs and symptoms of abruptio placentae include vaginal bleeding, abdominal pain, and uterine tenderness and contractions. Mild to severe uterine hypertonicity is present. Pains is mild to severe and either localized or diffuse over one region of the uterus, with a board-like abdomen.

Question 8

PLACENTA PREVIA

Answer 8

Painless vaginal bleeding and a soft, nontender uterus in the second or third trimester of pregnancy are signs of placenta previa.

Question 9

A nurse in the labor room is caring for a client who is in the first stage of labor. On assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Based on this finding, which is the appropriate nursing action?

Answer 9

Early deceleration of the FHR refers to a gradual decrease in the heart rate, followed by a return to baseline, in response to compression of the fetal head. It is a normal and benign finding. Because early decelerations are considered benign, interventions are not necessary.

Question 10

A woman in the third trimester of pregnancy visits the clinic for a scheduled prenatal appointment. The woman tells the nurse that she frequently has leg cramps, primarily when she is reclining. Once thrombophlebitis has been ruled out, the nurse should tell the woman to implement which measure to alleviate the leg cramps?

Answer 10

Leg cramps may be a result of

• compression of the nerves supplying the legs by the enlarging uterus,
• a reduced level of diffusible serum calcium, or
• an increase in serum phosphorus.
• • In the pregnant woman who complains of leg cramps, the nurse would perform further assessments to ensure that the client is not experiencing thrombophlebitis. Once this has been ruled out, the nurse would instruct the woman to place heat on the affected area, dorsiflex the foot until the spasm relaxes, or stand and walk. The health care provider may prescribe oral supplementation with calcium carbonate tablets or calcium hydroxide gel with each meal to increase the calcium level and lower the phosphorus level, but the nurse would not prescribe these or any other medications.

Question 11

A nurse is preparing a pregnant woman for a transvaginal ultrasound examination. The nurse should tell the woman that which will occur?

Answer 11

Transvaginal ultrasonography, in which a lubricated probe is inserted into the vagina, allows evaluation of the pelvic anatomy. A transvaginal ultrasound examination is well tolerated by most women because it alleviates the need for a full bladder to perform the test. The woman is placed in a lithotomy position or with her pelvis elevated by towels, cushions, or a folded blanket. The procedure is not physically painful, although the woman may feel pressure as the probe is moved.

Question 12

A client with portal-systemic encephalopathy is receiving oral lactulose (Chronulac) daily. The nurse should check which item to determine theeffectiveness of this medication?

Answer 12

Lactulose is a hyperosmotic laxative and ammonia detoxicant. It is used to prevent or treat portal-systemic encephalopathy, including hepatic precoma and coma. It also is used to treat constipation. The medication retains ammonia in the colon (decreases the blood ammonia concentration), producing an osmotic effect. It promotes increased peristalsis and bowel evacuation, expelling ammonia from the colon. This medication has no effect on lung sounds, the blood pressure, or the serum potassium level.

Question 13

The nurse notes that a client is receiving lamivudine (Epivir). The nurse determines that this medication has been prescribed to treat which condition?

Answer 13

Lamivudine is a nucleoside reverse transcriptase inhibitor and antiviral medication. It slows HIV replication and reduces the progression of HIV infection. It also is used to treat chronic hepatitis B and provide prophylaxis in health care workers who are at risk of acquiring HIV infection after occupational exposure to the virus.

Question 14

A nurse notes that a client is taking lansoprazole (Prevacid). On assessment of the client, the nurse should ask which question to determine the effectiveness of this medication?

Answer 14

HEARTBURN

Lansoprazole is a gastric acid pump inhibitor that is used to treat gastric and duodenal ulcers, erosive esophagitis, and hypersecretory conditions. It also is used to treat gastroesophageal reflux disease (GERD). I

Question 15

A client who has been hospitalized with a paranoid disorder refuses to turn off the lights in the room at night and states, “My roommate will steal me blind.” Which is the appropriate response by the nurse?

1. Why do you believe this?”
2. “Tell me more about the details of your belief.”
3. “I hear what you are saying, but I don’t share your belief.”
4. “If you want a pass for tomorrow evening’s movie, you’d better turn that light off this minute.”

Answer 15

Paranoid beliefs are coping mechanisms used by the client and therefore are not easily relinquished. It is important not to support the belief and not to ridicule, argue, or criticize it. Option 1 places the client in a defensive position by asking “why.” Option 2 encourages the client to expound on the belief when discussion should instead be limited. Option 4 threatens the client.

Question 16

A nurse is monitoring an infant for signs of increased intracranial pressure (ICP). On assessment of the fontanelles, the nurse notes that the anterior fontanelle bulges when the infant is sleeping. Based on this finding, which is the priority nursing action?

Answer 16

The anterior fontanelle is diamond shaped and is located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. A larger-than-normal fontanelle may be a sign of increased ICP within the skull. Although the anterior fontanelle may bulge slightly when the infant cries, bulging at rest may indicate increased ICP. Options 1 and 4 are inaccurate interventions and will not be helpful. Although the nurse would document the finding, the priority action would be to report the finding to the health care provider.

Question 17

The nurse is caring for a client who is receiving oxytocin (Pitocin) for induction of labor and notes a nonreassuring fetal heart rate (FHR) pattern on the fetal monitor. On the basis of this finding, the nurse should take which action first?

1. Stop the oxytocin infusion.
2. Check the client’s blood pressure.
3. Check the client for bladder distention.
4. Place the client in a side-lying position.

Answer 17

Oxytocin stimulates uterine contractions and is used to induce labor. If uterine hypertonicity or a nonreassuring FHR pattern occurs, the nurse needs to intervene to reduce uterine activity and increase fetal oxygenation. The oxytocin infusion is stopped, the client is placed in a side-lying position, and oxygen by face mask at 8 to 10 L/min is administered. The health care provider is notified. The nurse would monitor the client’s blood pressure and intake and output; however, the nurse would first stop the infusion.

Question 18

A nurse performs an assessment of a pregnant woman who is receiving intravenous magnesium sulfate for management of preeclampsia and notes that the woman’s deep tendon reflexes are absent. On the basis of this finding, the nurse should make which interpretation?

Answer 18

Magnesium toxicity can occur as a result of magnesium sulfate therapy.

Signs of magnesium sulfate toxicity relate to the central nervous system depressant effects of the medication and include respiratory depression, loss of deep tendon reflexes, sudden decrease in fetal heart rate or maternal heart rate or both, and sudden drop in blood pressure. An absence of reflexes indicates magnesium excess. The infusion rate therefore would not be increased.

Hyperreflexia indicates increased cerebral edema.

Question 19

Methylergonovine (Methergine) is prescribed for a woman with postpartum hemorrhage caused by uterine atony. Before administering the medication, the nurse should check which most importantclient parameter?

Answer 19

Methylergonovine is an ergot alkaloid used for postpartum hemorrhage. It stimulates contraction of the uterus and causes arterial vasoconstriction. Ergot alkaloids are avoided in women with significant cardiovascular disease, peripheral disease, hypertension, eclampsia, or preeclampsia. Such conditions are worsened by the vasoconstrictive effects of the ergot alkaloids. The nurse would assess the woman’s blood pressure before administering the medication and would follow agency protocols regarding withholding of the medication. Options 1, 2, and 3 are items that are assessed in the postpartum period, but they are unrelated to the use of this medication.

Question 20

The nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child’s arrival and plans to implement which type of precautions?

Answer 20

A major priority in nursing care for a child with suspected meningitis is to administer the appropriate antibiotic as soon as it is prescribed. The child will be placed in a private room, with droplet transmission precautions, for at least 24 hours after antibiotics are given. Enteric, contact, and neutropenic precautions are not associated with the mode of transmission of meningitis. Enteric precautions are instituted when the mode of transmission is through the gastrointestinal tract. Contact precautions are instituted when contact with infectious items or materials is likely. Neutropenic precautions are instituted when the client has a low neutrophil count.

Question 21

The clinic nurse reads the results of a tuberculin skin test performed on a 5-year-old child who is at low risk for contracting tuberculosis. The results indicate an area of induration measuring 10 mm. How would the nurse interpret these results?

Answer 21

Induration measuring 15 mm or greater is considered a positive result in a child 4 years of age or older who has no associated risk factors

Question 22

A nurse is monitoring a 7-year-old child who sustained a head injury in a motor vehicle crash for signs of increased intracranial pressure (ICP). The nurse should assess the child frequently for whichearly sign of increased ICP?

Answer 22

Nausea is an early sign of increased ICP.

Late signs of increased ICP include a significant decrease in level of consciousness, Cushing’s triad (increased systolic blood pressure and widened pulse pressure, bradycardia, and irregular respirations), and fixed and dilated pupils.

Other late signs include decreased motor response to command, decreased sensory response to painful stimuli, posturing, Cheyne-Stokes respirations, and papilledema.

Question 23

Cushing’s triad

Answer 23

Increased systolic blood pressure and widened pulse pressure

Bradycardia

Irregular respirations

Question 24

A nurse is preparing to administer digoxin (Lanoxin) to an infant with heart failure. Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 88 beats/minute. Based on this finding, which is the appropriate nursing action?

Answer 24

Digoxin is a cardiac glycoside that is used to treat heart failure. A primary concern is digoxin toxicity and the nurse needs to monitor closely for signs of toxicity and monitor digoxin blood levels. The medication is effective within a narrow therapeutic digoxin range (1.0 to 2.0 ng/mL). Safety in administration is achieved by double-checking the dose and counting the apical heart rate for 1 full minute. If the heart rate is less than 100 beats/minute in an infant, the nurse would withhold the dose and contact the health care provider.

Question 25

The nurse is performing an admission assessment on a client who has been admitted to the hospital with a diagnosis of **suspected gastric ulcer.** The nurse is asking the client questions about pain. Which statement, if made by the client, would support the diagnosis of gastric ulcer? ## Footnote The pain doesn't usually come right after I eat." "The pain gets so bad that it wakes me up at night." "The pain that I get is located on the right side of my chest." **"My pain comes shortly after I eat, maybe a half-hour or so later."**

Answer 25

**_Gastric ulcer pain_** often occurs in the upper epigastrium, with localization to the **left of the midline,** and **may be exacerbated by intake of food.** The pain occurs 30 to 60 minutes after a meal and **_rarely occurs at night._** **_Duodenal ulcer pain_** is usually located to the **right** of the epigastrium. **The pain associated with a duodenal ulcer occurs 90 minutes to 3 hours after eating and _often awakens the client at night._**

Question 26

The nurse is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which is in the client's hospital room as a priority item?

Answer 26

Monitoring for complications is an important aspect of initial postoperative care. Vital signs and pulse oximetry values are monitored closely until the client's condition stabilizes. The wound and any drains are **_monitored closely for excessive bleeding because hemorrhage is the primary immediate complication of amputation_**. Therefore a **_surgical tourniquet_** is kept at the bedside in case of acute bleeding. An over-bed trapeze increases the client's independence in self-care activities but is not a priority in the immediate postoperative period. An incentive spirometer and dry sterile dressings also should be available, but these are not priority items considering the surgical procedure that the client underwent.

Question 27

The nurse provides dietary instructions to a client with **_Ménière's disease_**. The nurse should tell the client that which food or fluid item is acceptable to consume?

Answer 27

The underlying pathological changes of Ménière's disease include overproduction and defective absorption of endolymph. This increases the volume and pressure within the membranous labyrinth until distention results in rupture and mixing of the endolymph and perilymph fluids. Dietary therapy frequently is quite helpful in controlling the symptoms associated with Ménière's disease. The nurse encourages the client to follow a low-salt diet and to avoid caffeine, sugar, monosodium glutamate, and alcohol.

Question 28

**Insulin glargine** (Lantus) is prescribed for a client with diabetes mellitus. The nurse should tell the client that it is best to take the insulin at which time?

Answer 28

Insulin glargine is a long-acting recombinant DNA human insulin that is used to treat type 1 and type 2 diabetes mellitus. It has a 24-hour duration of action and is administered once a day, usually at bedtime.

Question 29

A hospitalized client with a diagnosis of **schizophrenia** who is experiencing **delusions** says to the nurse, "I know that the doctor is talking to the top man in the mob to get rid of me." Which response should the nurse make to the client? ## Footnote I don't believe this is true." "The doctor is not talking to the mob." "What makes you think the doctor wants to get rid of you?" **"I don't know anything about the top man in the mob. Do you feel afraid that people are trying to hurt you?"**

Answer 29

When **_delusional,_** a **_client truly believes what he or she thinks to be real is real._** The client's thinking often reflects feelings of grea**_t fear and aloneness._** **It is most therapeutic for the nurse to empathize with the client's experience.** Disagreeing with delusions may make the client more defensive, and the client may cling to the delusions even more. **Encouraging discussion regarding the delusions is inappropriate.**

Question 30

A nurse is gathering data from a client with a phobia. The client tells the nurse that he consistently avoids attending community functions because he fears that he will be asked to speak publicly to the members. On the basis of this information, the nurse determines that the client is experiencing which condition?

Answer 30

**Social phobias** are characterized by severe anxiety or fear provoked by exposure to a social situation or a performance situation. Fear of public speaking is the most common social phobia. **Nyctophobia** is a fear of darkness. **Agoraphobia** is a fear of open spaces. **Claustrophobia** is a fear of closed places.

Question 31

The nurse is monitoring a client who is attached to a cardiac monitor and notes the **presence of U waves**. The nurse assesses the client and checks his or her most recent electrolyte results. The nurse expects to note which electrolyte value?

Answer 31

A serum potassium level lower than 3.5 mEq/L is indicative of hypokalemia. In **_hypokalemia_**, the electrocardiographic (ECG) changes that occur include **inverted T waves,** **ST segment depression,** heart block, and **prominent U waves.**

Question 32

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which cardiovascular manifestation would the nurse expect to note? 1. Hypotension 2. Increased heart rate 3. Bounding peripheral pulses 4. Shortened QT interval on electrocardiography (ECG)

Answer 32

Cardiovascular manifestations that occur with hypocalcemia include * decreased heart rate, * diminished peripheral pulses, and * hypotension. * On the electrocardiogram (ECG), the nurse would note a prolonged ST interval and a prolonged QT interval.

Question 33

The nurse is preparing to administer furosemide (Lasix) 40 mg by intravenous (IV) injection (IV push) to a client. The nurse should administer the medication over which time period?

Answer 33

When furosemide is administered by IV injection, each 40 mg or fraction thereof should be given over a **1- to 2-minute period.**

Question 34

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?

Answer 34

A nursing consideration in **_rubeola is eye care._** The child usually has **_photophobia_**, so the nurse should suggest that the parent keep the child out of brightly lit areas. Warm baths and sunlight will aggravate itching. Additionally, the child needs to rest. **Children with viral infections are not to be given aspirin because of the risk of Reye's syndrome.**

Question 35

A nurse reinforces medication instructions to a client who has received a kidney transplant about therapy with cyclosporine (Sandimmune). Which statement by the client would indicate a need for further instruction? "I need to obtain a yearly influenza vaccine." "I need to have dental checkups every 3 months." "I need to self-monitor my blood pressure at home." "I need to call the health care provider if my urine volume decreases or it becomes cloudy."

Answer 35

**_Cyclosporine_** is an **immunosuppressant medication.** Because of the effects of the medication, **the client should _not_ receive any vaccinations** without first consulting the health care provider. The client should report decreased urine output or cloudy urine, which could indicate kidney rejection or infection, respectively. The client needs **meticulous oral care** and dental cleaning ever**y 3 months to help _prevent gingival hyperplasia._** The client must be able to self-monitor blood pressure to check for the side effect of hypertension.

Question 36

A client who has received a kidney transplant is taking azathioprine (Imuran), and the nurse provides instructions about the medication. Which statement by the client would indicate a need for further instruction? "I need to watch for signs of infection." "I need to discontinue the medication after 14 days of use." "I can take the medication with meals to minimize nausea." "I need to call the health care provider if more than one dose is missed."

Answer 36

**Azathioprine is an immunosuppressant m**edication that is **_taken for life._** Because of the effects of the medication, the client must watch for signs of infection, which are to be reported immediately to the health care provider. The medication may be taken with meals to minimize nausea. The client should also call the health care provider if more than one dose is missed.

Question 37

A health care provider writes a prescription for **digoxin** (Lanoxin), 0.25 mg daily. The nurse teaches the client about the medication and tells the client that it is most important to be sure to implement which measure?

Answer 37

An important component of taking digoxin is monitoring the **pulse rate**; however, it is not necessary for the client to take both radial and carotid pulses. It is also unnecessary for the client to check the blood pressure every morning and evening because the medication does not directly affect blood pressure. It is most important for the client to know the guidelines related to withholding the medication and calling the health care provider. The client should not stop taking the medication.

Question 38

A client is taking ticlopidine hydrochloride (Ticlid). The nurse should tell the client to avoid which substance while taking this medication?

Answer 38

Ticlopidine hydrochloride is a **_platelet aggregation inhibitor_**. It is used to decrease the risk of thrombotic stroke in clients with precursor symptoms. Because it is an antiplatelet agent, other medications that precipitate or aggravate bleeding should be avoided during its use. Therefore, aspirin or any aspirin-containing product should be avoided.