Page 324 - Saunders Comprehensive Review For NCLEX-RN

the new graduate nurse, indicates the need for further teaching regarding
pain management?
1. “I will be sure to ask my client what his pain level is on a scale of 0
to 10.”
2. “I know that I should follow up after giving medication to make
sure it is effective.”
3. “I will be sure to cue in to any indicators that the client may be
exaggerating their pain.”
4. “I know that pain in the older client might manifest as sleep
disturbances or depression.”
66. A client has been admitted to the hospital for gastroenteritis and
dehydration. The nurse determines that the client has received adequate
volume replacement if the blood urea nitrogen (BUN) level drops to which
value?
1. 3 mg/dL (1.08 mmol/L)
2. 15 mg/dL (5.4 mmol/L)
3. 29 mg/dL (10.44 mmol/L)
4. 35 mg/dL (12.6 mmol/L)
67. The nurse is explaining the appropriate methods for measuring an accurate
temperature to an assistive personnel (AP). Which method, if noted by the
UAP as being an appropriate method, indicates the need for further
teaching?
1. Taking a rectal temperature for a client who has undergone nasal
surgery
2. Taking an oral temperature for a client with a cough and nasal
congestion
3. Taking an axillary temperature for a client who has just consumed
hot coffee
4. Taking a temperature on the neck behind the ear using an
electronic device for a client who is diaphoretic
68. A client is receiving a continuous intravenous infusion of heparin sodium to
treat deep vein thrombosis. The client’s activated partial thromboplastin time
(aPTT) is 65 seconds. The nurse anticipates that which action is needed?
1. Discontinuing the heparin infusion
2. Increasing the rate of the heparin infusion
3. Decreasing the rate of the heparin infusion
4. Leaving the rate of the heparin infusion as is
69. 69. A client with a history of heart failure is due for a morning dose of
furosemide. Which serum potassium level, if noted in the client’s laboratory
report, should be reported before administering the dose of furosemide?
1. 3.2 mEq/L (3.2 mmol/L)
2. 3.8 mEq/L (3.8 mmol/L)
3. 2 mEq/L (4.2 mmol/L)
4. 8 mEq/L (4.8 mmol/L)
70. Several laboratory tests are prescribed for a client, and the nurse reviews the
results of the tests. Which laboratory test results should the nurse report?
Select all that apply.

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