8/10/2019 32 Nclex Review

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Strategy: Answers are a mix of assessments and implementations. Does thissituation require assessment? Yes.

(1) implementation, done to prevent swelling and venous congestion, not helpful to

reduce paindue to circulatory impairment

(2) assessment, not helpful to reduce pain due to circulatory impairment, should notpalpate wet

cast, would result in depressions causing pressure(3) implementation, pain important diagnostic symptom, should not be suppressed

or masked

(4) correctassessment, pain main symptom of circulatory impairment from cast,pressing nail of great toe indicates circulatory function, compare speed with which

color returns with result on the opposite side, sluggish return indicates circulatoryimpairment, too rapid return indicates venous congestion

88. The nurse is caring for clients in the skilled nursing facility. Which of the

following clients require the nurses IMMEDIATE attention?

1. A client admitted for a cerebral vascular accident (CVA) whose prescription for

warfarin (Coumadin) expired two days ago.

2. A client in pain who was receiving morphine in an acute care institution and wastransferred with a prescription for acetaminophen with codeine.3. A client who has dysuria and foul-smelling, cloudy, dark amber urine.

4. An immunosuppressed client who has not received an influenza immunization.

Strategy: Determine the least stable client

(1) correctduration of Coumadin 25 days, client at risk for a repeat CVA(2) anticoagulant takes priority, client still receiving pain medication

(3) painful urination, may indicate infection(4) anticoagulant takes priority

89. An extremely agitated client is receiving haloperidol (Haldol) IM every

30 minutes while in the psychiatric emergency room. The MOST important

nursing intervention is to

1. monitor vital signs, especially blood pressure, every 30 minutes.2. remain at the clients side to provide reassurance.

3. tell the client the name of the medication and its effects.4. monitor the anticholinergic effects of the medication.

Strategy: Answers are a mix of assessments and implementations. Is this a

situation that requires assessment? Yes. Is there an appropriateassessment? Yes.

(1) correctassessment, monitoring vital signs is of utmost importance to ensure

client safety and physiological integrity; rapid neuroleptization is a pharmacological

intervention used to rapidly diminish severe symptoms that accompany acutepsychosis; alpha-adrenergic blockade of peripheral vascular system lowers BP andcauses postural hypotension

(2) implementation, should be done, but is not highest priority(3) implementation, should be done, but is not highest priority

(4) assessment, circulatory system takes priority