NCLEX RN Comprehensive B with NGN questions and answers with rationales graded A+

NCLEX RN
Comprehensive B
with NGN
questions and
answers with
rationales graded
A+


A nurse is assessing a client who is at 11 weeks of gestation and
reports drinking ginger tea. Which of the following findings
indicates the client's use of ginger tea is effective?
The client reports a decrease in episodes of nausea.
The client reports a decrease in breast tenderness.
The client reports a decrease in headaches.
The client reports a decrease in urinary frequency. - ANSWERThe client reports a decrease in episodes of nausea.
RATIONALE-The nurse should realize that a decrease in the
client's nausea indicates the ginger tea is effective. The client
can also safely use ginger ale and ginger snaps to alleviate
nausea associated with pregnancy.
The nurse is continuing to care for the adolescent.
Which of the following prescriptions should the nurse anticipate
from the provider?
For each potential provider's prescription, click to specify if the
potential prescription is anticipated or contraindicated for the
adolescent.
Potential Prescription
Prepare the adolescent for surgery.
Remove the splint.
Apply ice to the affected extremity.
Elevate the right leg above heart level. - ANSWER-Anticipated
Prepare the adolescent for surgery.
Remove the splint.
Contraindicated
Apply ice to the affected extremity.
Elevate the right leg above heart level.
RATIONALE-When generating solutions for an adolescent who
has compartment syndrome, the nurse should anticipate that
the adolescent will need a fasciotomy. A fasciotomy is needed to
decrease atrial spasms and increase perfusion within the muscle
compartments. The nurse should recognize that elevating the
right leg above heart level, and applying ice to the affected
extremity are all contraindicated for an adolescent who has
compartment syndrome. Elevating the right leg above heart
level and applying ice to the affected extremity will further
compromise blood flow.
The nurse is continuing to care for the adolescent.
The nurse is preparing the adolescent for the fasciotomy. Which
of the following findings should the nurse report to the provider
prior to surgery?
The adolescent has not voided in 4 hr.
The adolescent's blood pressure is 131/89 mm Hg.
The adolescent's parents have concerns regarding the surgery.
The adolescent reports severe pain. - ANSWER-The adolescent's
parents have concerns regarding the surgery.
RATIONALE-When taking actions for an adolescent who is
scheduled for a fasciotomy, the nurse should notify the provider
if the parents of the adolescent have questions or concerns
regarding the procedure, which could indicate lack of
understanding about the informed consent
The nurse is assessing the adolescent 4 hr following fasciotomy.
Click to highlight the findings below that indicate the
adolescent's condition is improving.
Adolescent is drowsy and reports nausea. Respirations shallow.
Lungs clear. Unproductive cough present. S1 and S2 with regular
rate and rhythm. Abdomen soft and nontender with hypoactive
bowel sounds in all four quadrants. Right lower extremity
fasciotomy, dressing clean, dry, and intact. Extremity pulse +3.
Capillary refill 2 seconds. Right extremity is warm to the touch.
Adolescent reports no numbness or tingling. Adolescent reports
pain as 2 on a scale of 0 to 10. - ANSWER-Extremity pulse +3.
Capillary refill 2 seconds. Right extremity is warm to the touch.
Adolescent reports no numbness or tingling. Adolescent reports
pain as 2 on a scale of 0 to 10.
RATIONALE-When evaluating outcomes, the nurse should
identify that the adolescent's extremity pulse, capillary refill,
skin temperature, no reports of numbness or tingling, and a
decrease in pain are all findings that indicate the fasciotomy was
effective. A fasciotomy is a surgical procedure that creates an
incision in the muscle fascia to relieve pressure within the
compartment. The relief of the pressure restores perfusion to
the area and reduces pain.