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Saunders NCLEX Questions with correct answers
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Saunders NCLEX Questions with correct answers
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Saunders NCLEX Questions with correctanswers
The |evening |nurse |reviews |the |nursing |documentation |in |the |client's |chart |and |notes |that
|the |day |nurse |has |documented |that |the |client |has |a |stage |2 |pressure |ulcer |in |the |sacral
|area. |Which |of |the |following |would |the |nurse |expect |to |note |on |assessment |of |the |client's
|sacral |area?
a. |Intact |skin
b. |Full-thickness |skin |loss
c. |Exposed |bone, |tendon, |or |muscle
d. |Partial-thickness |skin |loss |of |the |dermis |- |ANSWERS✔✔ |d. |Partial-thickness |skin |loss |of
|the |dermis
Rationale: |in |a |stage |II |pressure |ulcer, |the |skin |is |not |intact. |Partial-thickness |skin |loss |of |the
|dermis |has |occurred. |It |presents |as |a |shallow-open |ulcer |with |a |red-pink |wound |bed,
|without |slough. |It |may |also |present |as |an |intact, |open |or |ruptured, |serum-filled |blister. |The
|skin |is |intact |in |stage |I. |Full-thickness |skin |loss |occurs |in |stage |III. |Exposed |bone, |tendon, |or
|muscle |is |present |in |stage |IV.
A |nurse |is |preparing |a |teaching |plan |for |a |client |with |DM |regarding |proper |foot |care. |Which
|instruction |is |included |in |the |plan?
a. |Soak |feet |in |hot |water
b. |Avoid |using |a |mild |soap |on |the |feet
c. |Apply |a |moisturizing |lotion |to |dry |feet |but |not |between |the |toes
d. |Always |have |a |podiatrist |cut |your |toenails; |never |cut |them |yourself |- |ANSWERS✔✔ |c.
|Apply |a |moisturizing |lotion |to |dry |feet |but |not |between |the |toes
Rationale: |the |client |is |instructed |to |use |a |moisturizing |lotion |on |the |feet |and |to |avoid
|applying |the |lotion |between |the |toes. |The |client |should |be |instructed |not |to |soak |the |feet
,|and |should |avoid |hot |water |to |prevent |burns. |The |client |may |cut |the |toenail |straight |across
|and |even |with |the |toe |itself |and |would |consult |a |podiatrist |at |the |toenails |were |thick |or
|hard |to |cut |or |if |vision |were |poor. |The |client |should |be |instructed |to |wash |the |feet |daily
|with |a |mild |soap.
A |client |newly |diagnosed |with |DM |has |been |stabilized |with |daily |insulin |injections. |A |nurse
|prepares |a |discharge |teaching |plan |regarding |the |insulin |and |plans |to |reinforce |which |of
|the |following |concepts?
a. |Always |keep |insulin |vials |refrigerated
b. |Ketones |in |the |urine |signify |a |need |for |less |insulin
c. |Increase |the |amount |of |insulin |before |unusual |exercise
d. |Systemically |rotate |insulin |injections |within |one |anatomic |site |- |ANSWERS✔✔ |d.
|Systemically |rotate |insulin |injections |within |one |anatomic |site
Rationale: |insulin |doses |should |not |be |adjusted |nor |increased |before |unusual |exercise. |If
|ketones |are |found |in |the |urine, |it |possibly |may |indicate |the |need |for |additional |insulin. |To
|minimize |the |discomfort |associated |with |insulin |injections, |insulin |should |be |administered
|at |room |temperature. |Injection |sites |should |be |rotated |systematically |within |one |anatomic
|site.
A |client |with |a |diagnosis |of |diabetic |ketoacidosis |(DKA) |is |being |treated |in |an |emergency
|room. |Which |finding |would |a |nurse |expect |to |note |as |confirming |this |diagnosis?
a. |Comatose |state
b. |Decreased |urine |output
c. |Increased |respirations |in |an |increase |in |pH
d. |Elevated |blood |glucose |level |an |low |plasma |bicarbonate |level |- |ANSWERS✔✔ |d. |Elevated
|blood |glucose |level |an |low |plasma |bicarbonate |level
Rationale: |in |DKA, |the |arterial |pH |is |lower |than |7.35, |plasma |bicarbonate |is |a |lower |than |15
|mEq/L, |the |blood |glucose |level |is |higher |than |250 |mg/dL, |and |ketones |are |present |in |the
|blood |in |urine. |The |client |would |be |experiencing |polyuria, |and |Kussmaul's |respirations
, |would |be |present. |A |comatose |state |may |occur |if |DKA |is |not |treated, |but |coma |would |not
|confirm |the |diagnosis.
In |external |insulin |pump |is |prescribed |for |a |client |with |DM |in |the |client |ask |the |nurse |about
|the |functioning |of |the |pump. |The |nurse |bases |the |response |on |the |information |that |the
|pump:
a. |Is |timed |to |release |programmed |doses |of |regular |or |NPH |insulin |into |the |bloodstream |at
|specific |intervals
b. |Continuously |infuses |small |amounts |of |NPH |insulin |into |the |bloodstream |while |regularly
|monitoring |blood |glucose |levels
c. |Is |surgically |attached |to |the |pancreas |and |infuses |regular |insulin |into |the |pancreas |which
|in |turn |releases |the |insulin |into |the |bloodstream
d. |Gives |a |small |continuous |dose |of |regular |insulin |subcutaneously, |and |the |client |can |self-
administer |a |bolus |with |an |additional |dose |from |the |pump |before |each |meal |- |ANSWERS✔✔
|d. |Gives |a |small |continuous |dose |of |regular |insulin |subcutaneously, |and |the |client |can |self-
administer |a |bolus |with |an |additional |dose |from |the |pump |before |each |meal
Rationale: |an |insulin |pump |provides |a |small |continuous |dose |of |regular |insulin
|subcutaneously |throughout |the |day |and |night, |and |the |client |can |self-administer |a |bolus
|with |an |additional |dose |from |the |pump |before |each |meal |as |needed. |Regular |insulin |is |used
|in |an |insulin |pump. |An |external |pump |is |not |attached |surgically |to |the |pancreas.
A |nurse |teaches |a |client |with |a |DM |about |differentiating |between |hypoglycemia |and
|ketoacidosis. |The |client |demonstrates |an |understanding |of |the |teaching |by |stating |that
|glucose |will |be |taken |if |which |of |the |following |symptoms |develops?
a. |Polyuria
b. |Shakiness
c. |Blurred |vision
d. |Fruity |breath |odor |- |ANSWERS✔✔ |b. |Shakiness
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