Saunders Nclex – Cardiac
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A chaotic small, irregular, disorganized cardiac pattern suddenly appears on a client's cardiac monitor.
Which is the nurse's first action? - Answer -Check the client and the chest leads.
This t...
Saunders NCLEX SAFETY Latest Update
Comprehensive Questions with Correct
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A 1-year-old infant is admitted to the hospital for control of tonic-clonic seizures. The nurse helps
minimize the infant's risk for injury by implementing which interventions? Select all that apply. -
Answer -Removing any toy with bright blinking lights
Keeping the sides rails of the child's bed padded
Turning the infant on the side during any seizure
Having oxygen and suction available at the bedside
A client has a prescription to receive 1000 mL of 5% dextrose in 0.45% sodium chloride. After gathering
the appropriate equipment, the nurse takes which action first before spiking the IV bag with the tubing?
- Answer -Closes the roller clamp on the IV tubing
A client is being discharged to home following spinal laminectomy and fusion with insertion of a metal
implant. The nurse includes which instructions about activity after discharge? Select all that apply. -
Answer -Avoid activities that involve pulling or pushing.
Do not lift objects weighing more than 5 pounds.
Do not climb stairs until after the follow-up appointment with the surgeon.
A client is having trouble remembering his prescribed medication regimen. Which statement by the
nurse is therapeutic? - Answer -"Let me go over your prescribed medications with you again."
A client is receiving enteral feedings via a gastrostomy tube (G-tube). Which nursing measures are
necessary when caring for this client? Select all that apply. - Answer -Monitoring the skin around
the stoma site for skin irritation
Administering intermittent feeding through a 60-mL syringe with the plunger removed and the barrel
attached to the gastrostomy tube
A client with a diagnosis of tonic-clonic seizures is being admitted to the hospital, and the nurse needs to
institute seizure precautions. During a seizure, which items are inappropriate to use and could cause
harm to the client? Select all that apply. - Answer -Restraints
Padded tongue blade
A client with chronic pain has been taught how to operate a transcutaneous electrical nerve stimulation
(TENS) unit. Which client action shows understanding of the appropriate use of the device when the
level of stimulation is uncomfortable? - Answer -The client adjusts the setting downward slightly.
, A licensed practical nurse (LPN) asks an unlicensed assistive personnel (UAP) to gather supplies in
preparation for administering a tepid bath to a child with an elevated temperature. The LPN intervenes if
the UAP obtains which unnecessary item(s)? - Answer -A bottle of alcohol
A mother tells the pediatrician's office nurse that she is concerned because her children must let
themselves into the house after school each day while she is at work and they feel isolated and fearful.
The nurse should suggest which to the mother? - Answer -"You should seek community after-
school programs or activities for your children."
During a fire drill, the nurse enters a laundry room and a waste basket is marked as on "fire." The nurse
activates the alarm, closes the laundry room door, and obtains a fire extinguisher and returns to the
laundry room. Which action by the nurse shows that additional training is needed? - Answer -
Aiming at the top flames of the fire
The nurse administers an injection to a client with a diagnosis of acquired immunodeficiency syndrome
(AIDS). After administering the medication, the nurse should dispose of the used needle by which
method? - Answer -Placing the needle and syringe in a puncture-resistant container
The nurse admits a client who has seizure precautions prescribed. The client has a seizure just after the
nurse has implemented the precautions. Which actions should the nurse take? Select all that apply. -
Answer -Time the start and stop of the seizure.
Apply oxygen at 2L with nasal cannula.
Turn the client to the side and do not restrain.
Note the distinguishing characteristics of the seizure.
Turn on the suction machine with oral catheter.
The nurse applies wrist restraints, prescribed to prevent a client from pulling out a nasogastric tube. How
should the nurse determine that the restraints are not too constrictive? - Answer -Place two
fingers under the restraint to determine snugness.
The nurse considers the universal protocol for preventing wrong site, wrong procedure, and wrong
person surgery. Which are correct about this protocol? Select all that apply. - Answer -The surgeon
is the person that marks the area of the operative procedure.
The site marking is done before the client is brought to the surgical suite in the operating room.
The nurse determines that the client has a proper fitting of the crutches when which criteria have been
fulfilled? Select all that apply. - Answer -Handgrips are positioned so the elbows are bent
approximately 30 degrees.
The space between the axilla and the top of the crutch pad is 1½ to 2 inches.
The nurse can place 3 to 4 fingerbreadths between the axilla and the crutch pad.
The nurse enters a client's room and finds that the wastebasket is on fire. The nurse quickly assists the
client out of the room. Which is the next nursing action? - Answer -Activate the fire alarm
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