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Saunders NCLEX book Questions and Answers 100% correct
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Exam of 16 pages for the course Saunders comprehensive at Saunders comprehensive (Saunders NCLEX book)
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Saunders NCLEX book// 8th edition2. You're providing discharge teaching to a patient who was admitted with asthma. You discussed the early warning signs of an asthma attack and ask the patient to list some of them. Select all the correct early warning signs verbalized by the patient:
A. Easily fatigued with physical activity
B. Reduced peak flow meter reading
C. Chest retractions
D. Cyanosis
E. Wheezing with activity
F. Nighttime coughing
G. No relief with short-acting bronchodilator inhaler - answerA,B,E,F
A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client?
A. Stridor
B. Crackles
C. Wheezes
D. Diminished - answerC. Wheezes
Rational: asthma is a respiratory disorder characterized by recurrent episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-
pitched musical sounds heard when air passes through an obstructive or narrow lumen of a respiratory passageway. Stridor is a harsh sound noted with an upper airway obstruction and often signals a life-threatening emergency. Crackles are produced by air passing over retained airway secretions or fluid, or the sudden opening of collapsed airways. Diminished lung sounds are heard over lung tissue were poor oxygen exchange is occurring.
The nurse is preparing to insert a nasogastric tube into a client. The nurse should place the client in which position for insertion?
A. Right side
B. Low-Fowler's
C. High-Fowler's D. Supine with the head flat - answerC. High-Fowler's Rationale: during insertion of an NG tube, the client is placed in a sitting or high Fowlers
position to facilitate insertion of the tube and reduce the risk of pulmonary aspiration if the client should vomit.
A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure?
A. Lying in bed on the affected side
B. Lying in bed on the unaffected side
C. Sims position with the head of the bed flat
D. Prone with the head turned to the side and supported by pillow - answerB. Lying in bed on the unaffected side
Rationale: to facilitate removal of fluid from the chest, the client is positioned sitting at the edge of the bed leaning over the bedside table, with feet supported on a stool; or lying in bed on the unaffected side with the head of the bed elevated 30 to 45°
The nurse creates a plan of care for a patient with deep vein thrombosis. Which client position or activity in the plans should be included?
A. Out of bed activities as desired
B. Bedrest with the affected extremity kept flat
C. Bedrest with elevation of the affected extremity
D. Bedrest with the affected extremity in a dependent position - answerC. Bedrest with elevation of the affected extremity Rationale: for the client with deep vein thrombosis, elevation of the affected leg facilitates blood flow by the force of gravity and decreases venous pressure, which intern relieves Edema and pain.
The nurse is caring for a client who was one day post operative for a total hip replacement. Which is the best position in which the nurse should place the client?
A. Head elevated lying on the operative side
B. On the non-operative side with legs abducted
C. Side lying with the affected leg internally rotated
D. Side lying with the affected leg externally rotated - answerB. On the non-operative side with legs abducted
Rationale: positioning after a total hip replacement depends on the surgical techniques used, the method of implantation, the prosthesis, and the primary healthcare providers preference. Abduction is maintained when the client is in a supine position or positioned
on the non-operative side. Internal and X ternal rotation, adduction, or lying on the operative side is avoided to prevent displacement of the prosthesis The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse should place the client in which position?
A. Left Sims position
B. Right Sims position
C. On the left side of the body, with the head of the bed elevated 45°
D. On the right side of the body, with the head of the bed elevated 45° - answerA. Left Sims position
Rationale: for administering an enema, the client is placed in the left Sims position so that the enema solution can flow by gravity in the natural direction of the colon.
The nurse has just released the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully
during the next hour?
A. Urinary output of 20mL/hr
B. Temperature of 37.6°C (99.6°F)
C. Blood pressure of 100/70 mm Hg
D. Serous drainage on the surgical dressing - answerA. Urinary output of 20mL/ hr
Rationale: urine output should be maintained at a minimum of 30mL/hr. An output of less than 30 mL for two consecutive hours should be reported to the surgeon. A temperature higher than 100°F or lower than 97°F in a failing systolic blood pressure, lower than 90, are usually considered reportable immediately. Serous drainage is normal.
The nurse is teaching a client about coughing and deep breathing techniques to prevent
a postoperative complication. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques?
A. "Use of an incentive spirometer will help prevent pneumonia"
B. "Close monitoring of your oxygen saturation will detect hypoxemia"
C. "Administration of intravenous fluids will prevent or treat fluid imbalance"
D. "Early ambulation and administration of blood thinners will prevent pulmonary embolism" - answerA. "Use of an incentive spirometer will help prevent pneumonia"
Rationale: postoperative respiratory problems are atelectasis, pneumonia, and pulmonary emboli. Pneumonia is the inflammation of lung tissue that causes productive cough, dyspnea, and lung crackles and can be caused by retained pulmonary secretions. Use of an incentive spirometer helps prevent pneumonia and atelectasis. Hypoxemia is an in adequate concentration of oxygen in arterial blood. While close monitoring of the oxygen saturation will help detect hypoxemia, monitoring is not directly
related to coughing and deep breathing techniques
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