Saunders Comprehensive Review for NCLEX FOUR-TEST BANK | Contains 1140 Highly Tested Q&A for Best NCLEX EXAMS Prep

The nurse would anticipate that the health care provider
(HCP) would add which medication to the regimen of the
client receiving isoniazid?
 Pyridoxine
2) A postpartum nurse is caring for a client with an epidural
catheter in place for opioid analgesic administration
following cesarean birth. The client develops respiratory
depression and requires naloxone administration. Which
finding should the nurse anticipate as a result of the
naloxone administration?
 Increase in pain level
3) The nurse should monitor the client receiving the first dose
of albuterol for which side or adverse effect of this
medication?
 Tachycardia
4) The client has a prescription to receive pirbuterol 2 puffs
and beclomethasone dipropionate 2 puffs by metered-dose
inhaler. The nurse plans to give these medications in which
way to ensure effectiveness?
 Administering the pirbuterol
before the beclomethasone
5) A client with chronic obstructive pulmonary disease (COPD)
is being changed from an oral glucocorticoid to
triamcinolone by inhalation. The client asks why this change
is necessary. Which statement by the nurse to the client is
accurate?
 "Inhaled glucocorticoids are
preferred because of decreased
adverse effects."
6) A client taking theophylline has a serum theophylline level
of 15 mcg/mL (60 mcmol/L). How does the nurse interpret this
laboratory value?
 In the middle of the
therapeutic range
7) A client is taking cetirizine. The nurse should inform the
client of which side effect of this medication?
 Drowsiness
8) A client is scheduled to receive acetylcysteine 20% solution
diluted in 0.9% normal saline by nebulizer. Which outcome
would the nurse expect as a result of the administration of
this medication?
 Thinning of respiratory secretions
9) The health care provider prescribes cromolyn for the client
with asthma. The nurse identifies that the client correctly
understands the purpose of this medication when the client
states that the medication will produce which effect?

10) The nurse is teaching a client about the effects of
diphenhydramine, an ingredient in the cough suppressant
prescribed for the client. The nurse should plan to tell the
client to take which measure while taking this medication?
 Avoid activities requiring mental
alertness.
11) The health care provider (HCP) has prescribed codeine
sulfate for a client with a nonproductive cough to suppress
the cough reflex. The nurse should teach the client to
monitor for which side effect of the medication?
 Constipation
12) A client has begun therapy with a xanthine
bronchodilator. The nurse determines that the client
understands dietary alterations if the client states to
limit which items while taking this medication? Select all
that apply.
 Coffee
 Chocolate
13) Which supplies should the nurse obtain for the
administration of ribavirin to a hospitalized child with
respiratory syncytial virus (RSV)?
 A mask and pair of goggles
14) The nurse is documenting information in a client's
chart when the electrocardiogram telemetry alarm sounds, and
the nurse notes that the client is in ventricular 
tachycardia (VT). The nurse rushes to the client's bedside
and should perform which assessment first?
 Check responsiveness
15) A client is brought into the emergency department in
ventricular fibrillation (VF). The nurse prepares to
defibrillate by placing defibrillation pads on which part of
the chest?
 To the right of the sternum and to
the left of the precordium
16) An adult client has been unsuccessfully defibrillated
for ventricular fibrillation, and cardiopulmonary
resuscitation (CPR) is resumed. The nurse confirms that CPR
is being administered effectively by noting which action
 The carotid pulse is palpable with
each compression.
17) The nurse is assigned the care of a client who
experienced a myocardial infarction and is being monitored
by cardiac telemetry. The nurse notes the sudden onset of
this cardiac rhythm on the monitor. The nurse should
immediately take which action? Refer to Figure.
View Figure
 Initiate cardiopulmonary
resuscitation (CPR).
18) To perform defibrillation, the defibrillator pads
should be placed in which areas of the client's chest?
 To the right of the sternum just
below the clavicle and to the left
side, just below and to the left of
the pectoral muscle
19) The nurse is caring for a client who is pulseless and
experiencing this dysrhythmia. Which interventions should
the nurse anticipate implementing in collaboration with the
health care provider (HCP)? Select all that apply. Refer to
Figure.
View Figure
 Prepare to administer amiodarone.
 Prepare to administer epinephrine.
 Provide cardiopulmonary resuscitation
(CPR).
20) The nurse is performing cardiopulmonary resuscitation
(CPR) on a client who has had a cardiac arrest. An automatic
external defibrillator (AED) is available to treat the
client. Which activity will allow the nurse to assess the
client's cardiac rhythm?
 Apply adhesive patch electrodes to the
chest and move away from the client.
21) The nurse is teaching adult cardiopulmonary
resuscitation (CPR) guidelines to a group of laypeople. The
nurse observes the group correctly demonstrate 2-rescuer CPR
when which ratio of compressions to ventilations is
performed on the mannequin?
 30:2
22) The nurse is teaching cardiopulmonary resuscitation
(CPR) to a group of community members. The nurse tells the
group that when chest compressions are performed on infants,
the sternum should be depressed how far?
 About 1½ inches (4 cm)
23) The nursing instructor teaches a group of students
about cardiopulmonary resuscitation. The instructor asks a
student to identify the most appropriate location at which
to assess the pulse of an infant younger than 1 year of age.
Which response would indicate that the student understands
the appropriate assessment procedure?
 Brachial artery
24) The nurse is conducting a basic life support (BLS)
recertification class and is discussing chest compressions
in a pregnant woman. The nurse should tell the class that
which action should be taken in an advanced pregnancy client
whose fundal height is at or above the umbilicus?
 Maintain manual left uterine
displacement during compressions.
25) The nurse is initiating 1-rescuer cardiopulmonary
resuscitation on an adult client. The nurse should place the
hands in which position to begin chest compressions?
 On the lower half of the
sternum
26) The nurse walking in a downtown business area witnesses
a worker fall from a ladder. The nurse rushes to the victim,
who is unresponsive. A layperson is attempting to perform
resuscitative measures. The nurse should intervene if which
action by the layperson is noted?
 Use of the head tilt–chin lift
27) The nurse notes that a 14-year-old child is choking but
is awake and alert at this time. The nurse rushes to perform
the abdominal thrust maneuver. The child becomes
unconscious. What procedure should the nurse perform next?
 Start chest compressions.
28) The nurse assigned to the pediatric unit finds an
infant unresponsive and without respirations or a pulse.
What is the nurse's next action after calling for help?
 Perform compressions at 100 to
120 times per minute.
29) The nurse is undergoing annual recertification in basic
life support (BLS). The BLS instructor asks the nurse to
identify the pulse point to use when determining
pulselessness on an infant. Which response by the nurse
identifies the most appropriate pulse point?
 Brachial
30) External public access defibrillator (PAD) interprets
that the rhythm of a pulseless victim is ventricular
fibrillation and advises defibrillation. Which action should
the rescuer take next?
 Order people away from the
client, charge the machine, and
depress the discharge buttons.
31) Cardiopulmonary resuscitation (CPR) is immediately
initiated on a client who is unconscious and has no pulse. A
monitor is attached and it is determined that the rhythm is 
shockable, and defibrillation with 1 shock is delivered.
Which action should the nurse plan to take next?
 Perform CPR for 5 cycles, and
then defibrillate again if the
rhythm is shockable.
32) The nurse has completed 5 cycles of compressions after
beginning cardiopulmonary resuscitation (CPR) on a
hospitalized adult client who experienced unmonitored
cardiac arrest. What should the nurse plan to do next?
 Charge the defibrillator.
33) The nurse is teaching chest compressions for
cardiopulmonary resuscitation (CPR) to a group of lay
clients. Which behavior by one of the participants indicates
a need for further teaching?
 Letting the right and left
fingers rest on the chest
34) In order of priority, how should the nurse perform
abdominal thrusts on an unconscious adult? Arrange the
actions in the order that they should be performed. All
options must be used.
 1,2,3,4,5
35) One unit of packed red blood cells has been prescribed
for a client with severe anemia. The client has received
multiple transfusions in the past, and it is documented that
the client has experienced urticaria-type reactions from the
transfusions. The nurse anticipates that which medication
will be prescribed before administration of the red blood
cells to prevent this type of reaction?
 Diphenhydramine
36) The nurse has a prescription to administer whole blood
to a client who does not currently have an intravenous (IV)
line inserted. When obtaining supplies to start the blood
infusion, the nurse should select an angiocatheter of at
least which size?
 19 gauge
37) A client has experienced high blood pressure and
crackles in the lungs during previous blood transfusions. 
The client asks the nurse whether it is safe to receive
another transfusion. The nurse explains that which
medication most likely will be prescribed before the
transfusion is begun?
 Furosemide
38) The nurse is told by a health care provider that a
client in hypovolemic shock will require plasma expansion.
The nurse should prepare which supplies for transfusion?
 Bottle of albumin with vented
tubing
39) The nurse has discontinued a unit of blood that was
infusing into a client because the client experienced a
transfusion reaction. After documenting the incident
appropriately, the nurse sends the blood bag and tubing to
which department?
 Blood bank
40) The nurse has just obtained a unit of blood from the
blood bank to transfuse into a client as prescribed. Before
preparing the blood for transfusion, the nurse looks for
which member of the health care team to assist in checking
the unit of blood?
 Registered nurse (RN)
41) The nurse is picking up a unit of packed red blood
cells at the hospital blood bank. After putting the pen
down, the nurse glances at the clock, which reads 1300. The
nurse calculates that the transfusion must be started by
which time?
 1330
42) The nurse enters a client's room to assess the client,
who began receiving a blood transfusion 45 minutes earlier,
and notes that the client is flushed and dyspneic. On
assessment, the nurse auscultates the presence of crackles
in the lung bases. The nurse determines that this client
most likely is experiencing which complication of blood
transfusion therapy?
 Circulatory overload
43) The nurse is monitoring a client who is receiving a
blood transfusion. After 30 minutes of the infusion, the
client begins to have chills and back pain. His temperature
is 100.1°F (37.8°C). What action should the nurse take
first?
 Discontinue the infusion and
start an infusion of normal saline
using new tubing.
44) The nurse enters the room of a client who began
receiving a blood transfusion 45 minutes earlier to check on
the client. The client is complaining of "itching all over"
and has a generalized rash. The client's temperature has not
changed from baseline and the lungs are clear to
auscultation. Which complication of blood transfusion
therapy should the nurse determine that this client is most
likely experiencing?
 Allergic transfusion reaction
45) A unit of platelets was just received from the blood
bank for transfusion to an assigned client. The nurse should
select tubing with which feature for the transfusion?
 An in-line filter
46) The nurse overhears a health care provider (HCP)
stating that a client diagnosed with disseminated
intravascular coagulation (DIC) requires a transfusion.
Which blood product should the nurse anticipate that the HCP
will write a prescription for?
 Cryoprecipitate
47) The nurse is assisting in monitoring a client who is
receiving a transfusion of packed red blood cells (PRBCs).
Before leaving the room, the nurse tells the client to
immediately report which symptoms of a transfusion reaction?
Select all that apply.
 Chills
 Chest pain
 Lower back pain
 Difficulty breathing
48) A child is receiving succimer fo