Module 9 NCLEX

A client has just been scheduled for endoscopic retrograde cholangiopancreatography (ERCP). What should the nurse tell the client about the procedure? Select all that apply. a) That food and fluids will be withheld before the procedure b) That informed consent is required c) That multiple position changes may be necessary to pass the tube d) That the test takes about 4 hours to complete e) That no premedication for sedation will be necessary

A, B, C Rationale: The client must sign informed consent before the procedure, which takes about an hour to perform. Intravenous sedation is given to relax the client, and an anesthetic spray is used to help keep the client from gagging as the endoscope is passed. Food and fluids are withheld before the procedure to prevent aspiration. Multiple position changes may be necessary to facilitate the passage of the tube.

A client has the following arterial blood gas (ABG) results: pH 7.51, PaCO231 mm Hg (4.12 kPa), PaO2 94 mm Hg (12.45 kPa), HCO3 24 mEq/L (24 mmol/L). Which acid-base disturbance does the nurse recognize in these results? a) Metabolic acidosis b) Respiratory alkalosis c) Respiratory acidosis d) Metabolic alkalosis

B

A client has just undergone a renal biopsy. Which intervention should the nurse include in the post-procedure plan of care? a) Having the client ambulate in the room and hall for short distances b) Periodically testing the urine for occult blood c) Restricting fluid intake for the first 24 hours d) Avoiding the administration of opioid analgesics

B Rationale: After renal biopsy, bed rest is maintained and the client's vital signs and puncture site are assessed frequently. Urine is tested periodically for occult blood to detect bleeding as a complication. Fluids are encouraged to reduce the risk of clot formation at the biopsy site. Opioid analgesics are often needed to manage the renal colic pain that some clients feel after this procedure.

A nurse is assessing the status of a client with diabetes mellitus. The nurse concludes that the client is exhibiting adequate diabetic control if the serum level of glycosylated hemoglobin A1C (HbA1C) is less than which value? a) 15% b) 10% c) 7% d) 9%

C Rationale: An acceptable measure of diabetic control is present if the client's glycosylated HbA1C is 7.0% or less. Specific values may vary slightly, depending on the laboratory and the procedure. The other options indicate poor control of diabetes.

Oxygen by way of nasal cannula has been prescribed for a client with emphysema. The nurse checks the primary health care provider's prescriptions to ensure that the prescribed flow is not greater than which liter (L) per minute (min)? a) 6 L/min b) 1 L/min c) 3 L/min d) 4 L/min

C Rationale: Because the client with emphysema has long-standing hypercapnia, the respiratory drive is triggered by a low oxygen level rather than by a high carbon dioxide level. Too much oxygen in this client could cause respiratory failure. The client with emphysema usually receives oxygen at a flow rate of 1 to 2 (and no more than 3) L/min.

A nurse reviews the blood gas results of a client in respiratory distress. The pH is 7.32 and the PaCO2 is 50 mm Hg (6.65 kPa). Which acid-base imbalance does the nurse recognize in these findings? a) Respiratory alkalosis b) Metabolic alkalosis c) Metabolic acidosis d) Respiratory acidosis

D

A nurse has a prescription to collect a 24-hour urine specimen from a client. Which measure should the nurse take during this procedure? a) Saving the first urine specimen collected at the start time b) Keeping the specimen at room temperature c) Discarding the last voided specimen at the end of the collection time d) Asking the client to void, discarding the specimen, and noting the start time

D Rationale: Because the 24-hour urine collection is a timed quantitative determination, the test must be started with an empty bladder. Therefore the first urine is discarded. Fifteen minutes before the end of the collection time, the client should be asked to void, and this specimen is added to the collection. The collection should be refrigerated or placed on ice to help prevent changes in urine composition.

A client is brought to the emergency department by a neighbor. The client is lethargic and has a fruity odor on the breath. The client's arterial blood gas (ABG) results are pH 7.25, PaCO234 mm Hg (4.52 kPa), PaO2 86 mm Hg (11.3 kPa), HCO3 14 mEq/L (14 mmol/L). Which acid-base disturbance does the nurse recognize in these results? a) Respiratory acidosis b) Respiratory alkalosis c) Metabolic alkalosis d) Metabolic acidosis

D Rationale: The normal pH is 7.35 to 7.45. The normal PaCO2 is 35-45 mm Hg (4.66-5.98 kPa). The normal HCO3 (bicarbonate) is 22-26 mEq/L (22-26 mmol/L). The normal PaO2 is 80-100 mm Hg (10.6-13.33 kPa). Acidosis is defined as a pH of less than 7.35; alkalosis is defined as a pH greater than 7.45. Metabolic acidosis is present when the HCO3 is less than 22 mEq/L (22 mmol/L); metabolic alkalosis is present when the HCO3 is greater than 26 mEq/L (26 mmol/L). This client's ABG values are consistent with metabolic acidosis.

A client is tested for HIV with the use of an enzyme-linked immunosorbent assay (ELISA), and the test result is positive. The nurse should provide which information to the client about the test? The test will need to be confirmed with the use of a Western blot The client probably has an opportunistic infection A positive test is a normal result and does not mean that the client is infected with HIV HIV infection has been confirmed

a

A client reports for a scheduled electroencephalogram (EEG). Which statement by the client indicates a need for additional preparation for the test? "I didn't shampoo my hair." "I didn't take my anticonvulsant today." "It was hard not to drink coffee this morning, but I knew that I couldn't, so I didn't." "I ate breakfast this morning."

a Rationale: Pre-procedure care for EEG involves client teaching about the procedure, ensuring that the client's hair has been freshly shampooed, and providing a light meal and fluids to prevent hypoglycemia, which could alter brain waves. Medications such as antidepressants, tranquilizers, and anticonvulsants are withheld for 24 to 48 hours before the procedure as prescribed. Stimulants such as coffee, tea, cola, alcohol, and cigarettes are also withheld

Blood for arterial blood gas determinations is drawn on a client with pneumonia, and testing reveals a pH of 7.45, PaCO2 of 30 mm Hg (3.99 kPa), and HCO3 of 19 mEq/L (19 mmol/L). The nurse interprets these results as indicative of which disorder? Compensated respiratory alkalosis Uncompensated metabolic alkalosis Uncompensated respiratory acidosis Compensated metabolic acidosis

a Rationale: The normal pH is 7.35 to 7.45. The normal PaCO2 is 35-45 mm Hg (4.66-5.98 kPa). The normal HCO3 (bicarbonate) is 22-26 mEq/L (22-26 mmol/L). In a respiratory condition, opposite effects will be seen in pH and PaCO2. In respiratory alkalosis, pH is increased and PaCO2 is decreased. Compensation occurs when the pH returns to within the normal range, even though either the carbon dioxide or bicarbonate (or both) is abnormal value. In a metabolic condition, pH and bicarbonate move in the same direction. Clients with pneumonia are at risk for respiratory alkalosis as a result of hypoxemia.

A nurse is reviewing laboratory results for a newly admitted client. Which serum lab result does the nurse document as abnormal? Serum creatinine 0.2 mg/dL (17.6 μmol/L) Prothrombin time 11.0 to 12.5 seconds; 85% to 100% Serum sodium (NA) 136 to 145 mEq/L or 136/145 mmol/L (SI units) Sodium cholesterol

a Rationale: The normal serum creatinine level ranges from 0.6 to 1.3 mg/dL (53-115 μmol/L). A result of 0.2 mg/dL (17.6 μmol/L) represents a low value; the other incorrect options are normal values.

A serum phenytoin determination is prescribed for a client with a seizure disorder who is taking phenytoin. Which result indicates that the prescribed dose of phenytoin is therapeutic? 16 mcg/mL (63 µmol/L) 8 mcg/mL (32 µmol/L) 3 mcg/mL (12 µmol/L) 28 mcg/mL (111 µmol/L)

a Rationale: The therapeutic serum phenytoin range is 10 to 20 mcg/mL (40 to 79 µmol/L). If the level is below the therapeutic range, the client may continue to experience seizure activity. If the level is too high, the client is at risk for phenytoin toxicity.

A nurse is watching as a nursing student suctions a client through a tracheostomy tube. Which actions on the part of the student would prompt the nurse to intervene and demonstrate correct procedure? Select all that apply. Placing the client in a supine position before the procedure Setting the suction pressure to 60 mm Hg Applying suction throughout the procedure Hyperoxygenating the client with 100% oxygen before suctioning Assessing breath sounds before suctioning

a, b, c Rationale: The client with a tracheostomy tube should be positioned with the head of the bed elevated. Correct suction pressure for the adult client is 80 to 120 mm Hg. Suction is applied intermittently during catheter withdrawal. Breath sounds should be assessed before the procedure to help determine the need for suctioning. The client should be hyperoxygenated with 100% oxygen before suctioning.

A nurse reviews a client's urinalysis report. Which findings does the nurse recognize as abnormal? Select all that apply. Glucose noted Casts apparent The presence of ketones Specific gravity of 1.018 pH of 6.0 Incorrect An absence of protein

a,b,c Rationale: The normal pH range of urine is 4.5 to 7.8, and normal specific gravity ranges from 1.016 to 1.022. The urine is typically screened for protein, glucose, ketones, bilirubin, casts, crystals, red blood cells, and white blood cells, none of which should be present.

The nurse is caring for a client with a diagnosis of suspected uric acid calculi. The nurse is carefully checking the history of the client. What areas should the nurse focus on? Select all that apply. Previous episodes of stone formation Family history of urinary calculi History of anemia Dietary supplements Prescribed and OTC medications Previous problems with fluid overload 8.9 mg/dL (529.9 μmol/L)

a,b,d,e Rationale: A careful history should include any previous episodes of uric acid stone formation, prescribed and OTC medications, dietary supplements, and family history of urinary calculi. A history of anemia and fluid overload are not related to uric acid calculi areas.

An adult female client has undergone a routine health screening in the clinic. Which of the following values indicates to the nurse that some of the client's lab data are abnormal? Select all that apply. a) LDL Cholesterol 140 b) Magnesium (MG) 2.2 mEq/L c) Hematocrit (HCT) 30% (0.30) d) Bicarbonate 21 mEqL e) Calcium (CA) 9 mg/dL f) Sodium (NA) 149 mEq/L

a,c,d,f Rationale: A sodium (NA) level of 149 is elevated. Normal NA levels are 135 to 145 mEq/L. Hematocrit (HCT) level of 30% is low. Normal HCT levels are 40% to 54% in males and 37% to 47% in females. Calcium (CA) 9 mg/dL is normal. Normal calcium levels are8.5 to 10.5 mg/dL. LDL Cholesterol 140 is borderline high. Optimal LDL is 100 to 129. Magnesium 2.2 mEq/L is normal. Normal magnesium levels are 1.5 to 2.5 mEq/L. Bicarbonate level of 21 mEqL is low. Normal bicarb is 24 to 28 mEq/L.

A client who has undergone an esophagogastroduodenoscopy (EGD) returns from the endoscopy department. After checking the client's gag reflex, which action should the nurse take? Giving the client a drink of water Taking the client's vital signs Being alert to complaints of heartburn Monitoring the client for a sore throat

b

A client with cardiovascular disease is scheduled to receive a daily dose of furosemide. Which potassium level would cause the nurse, reviewing the client's electrolyte values, to contact the primary health care provider before administering the dose? 3.8 mEq/L (3.8 mmol/L) 3.0 mEq/L (3.0 mmol/L) 5.2 mEq/L (5.2 mmol/L) 4.2 mEq/L (4.2 mmol/L)

b

A nurse is reviewing the results of serum laboratory studies of a client with suspected hepatitis. Which increased parameter is interpreted by the nurse as the most specific indicator of this disease? Blood urea nitrogen (BUN) Serum bilirubin Erythrocyte sedimentation rate (ESR) Hemoglobin

b Rationale: Laboratory indicators of hepatitis include increased liver enzymes, serum bilirubin level, and ESR. However, ESR is a nonspecific test that indicates the presence of inflammation somewhere in the body. An increased BUN may indicate renal dysfunction. The hemoglobin level is unrelated to this diagnosis.

A nurse has a prescription to discontinue a client's nasogastric tube. The nurse auscultates the client's bowel sounds, positions the client properly, and flushes the tube with 15 mL of air to clear secretions. The nurse then instructs the client to take a deep breath followed by what client action? Exhale during tube removal Hold the breath during tube removal Breathe normally during tube removal Bear down during tube removal

b Rationale: The client is asked to take a deep breath because the airway will be temporarily obstructed during tube removal. The client is then asked to hold the breath while the tube is being withdrawn. Bearing down and exhaling could each interfere with tube removal by increasing intrathoracic pressure. Normal breathing could result in aspiration of gastric secretions during inhalation.

A nurse in a primary health care provider's office has just made an appointment for a client to undergo an exercise stress test. The nurse, in providing pre-procedure teaching, should provide which information to the client? Wear sweatpants and a heavy sweatshirt Wear comfortable rubber-soled shoes such as sneakers Eat a small meal just before the procedure Avoid consuming caffeine for 30 minutes before the procedure

b Rationale: The client should wear comfortable rubber-soled shoes, such as sneakers, for the procedure. The client wears light, loose, comfortable clothing; a shirt that buttons in front is helpful for electrocardiogram (ECG) lead placement. The client should be NPO after bedtime, or for a minimum of 2 hours before the test, and should avoid tobacco, alcohol, and caffeine on the day of the test.

A nurse is reading the radiology report of a client who has a chest tube attached to a closed drainage system and has undergone chest x-ray. The report states that the client's affected lung is fully re-expanded. The nurse anticipates that the assessment of the chest tube system will reveal which finding? Continuous bubbling in the water seal chamber No fluctuation in the water seal chamber Continuous gentle suction in the suction control chamber Increased drainage in the collection chamber

b Rationale: When the client's lung is fully re-expanded, the drainage system will no longer drain and fluctuation in the water seal chamber will be absent. This is because the lung has re-expanded and the pleural space is again a potential space. Continuous bubbling in the water seal chamber indicates an air leak in the system. Continuous gentle suction in the suction control chamber means that suction is being applied to the system.

A client who experienced the sudden onset of respiratory distress has been intubated with an endotracheal tube. After the tube is placed in the trachea, the nurse should take which immediate action? Send the client for a chest x-ray Tape the tube in place Auscultate both lungs for the presence of breath sounds Note how far the tube has been inserted

c

A nurse is caring for a client who has lost a significant amount of blood as a result of complications during a surgical procedure. Which parameter does the nurse recognize as the earliest indication of new decreases in fluid volume? Pulmonary artery systolic pressure Pulmonary artery end-diastolic pressure Pulse rate Blood pressure

c

A nurse is caring for a client with diarrhea. For which acid-base disorder does the nurse assess the client? Metabolic alkalosis Respiratory acidosis Metabolic acidosis Respiratory alkalosis

c

A client with type 1 diabetes mellitus has a blood glucose level of 620 mg/dL (34.4 mmol/L). After the nurse calls the primary health care provider to report the finding and monitors the client closely for which condition? Metabolic alkalosis Respiratory alkalosis Metabolic acidosis Respiratory acidosis

c Rationale: Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises. At the same time, the cells of the body use all available glucose. The body then breaks down glycogen and fat for fuel. The byproducts of fat metabolism, which are acidotic, can cause the condition known as diabetic ketoacidosis. The other options are incorrect and are not likely to occur in the client with diabetes mellitus.

A nurse is caring for a client who is vomiting. For which acid-base imbalance does the nurse assess the client? Metabolic acidosis Respiratory alkalosis Metabolic alkalosis Respiratory acidosis

c Rationale: Loss of gastric fluid by way of nasogastric suction or vomiting results in metabolic alkalosis. This is because of the loss of hydrochloric acid, a potent acid. The situation results in an alkalotic condition. The respiratory system is not involved.

A client has just undergone insertion of a chest tube that is attached to a closed chest drainage system. Which action should the nurse plan to take in the care of this client? Adding 20 mL of sterile water to the suction control chamber every shift Assessing the client's chest for crepitus once every 24 hours Taping the connections between the chest tube and the drainage system Recording the volume of secretions in the drainage collection chamber every 24 hours

c Rationale: The nurse tapes all system connections to prevent accidental disconnection. Drainage is noted and recorded every hour during the first 24 hours after insertion and every 8 hours thereafter. Assessment for crepitus is performed once every 8 hours or more often if needed. Sterile water is only added to the suction control chamber as needed to replace evaporative loss.

nurse is assessing the chest tube system of a client who has undergone a lobectomy. The system contains 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water seal chamber. One hour after, the nurse notes that the bubbling in the water seal chamber is now constant, and the client appears dyspneic. On the basis of these findings, what should the nurse assess first? The amount of drainage The client's lung sounds The chest tube connections The client's vital signs

c Rationale: The client's dyspnea is most likely related to an air leak caused by a loose connection. Other causes might be a tear or incision in the pulmonary pleura, which requires primary health care provider intervention. Although the interventions identified in the other options should also be taken in this situation, they should be performed only after the nurse has tried to locate and correct the air leak. It only takes a moment to check the connections, and if a leak is found and corrected, the client's signs/symptoms should resolve.

A client with a history of lung disease is at risk for respiratory acidosis. For which signs/symptoms does the nurse assess this client? Drowsiness, headache, and tachypnea Tachypnea, dizziness, and paresthesias Dysrhythmias and decreased respiratory rate and depth Disorientation and dyspnea

d

A nurse is helping a client with a closed chest tube drainage system get out of bed and into a chair. During the transfer, the chest tube is caught on the leg of the chair and dislodged from the insertion site. What is the immediate nursing action? Transfer the client back to bed Contact the primary health care provider Reinsert the chest tube Cover the insertion site with a sterile occlusive dressing

d

A nurse is admitting a client with a diagnosis of hypothermia to the hospital. Which signs/symptoms does the nurse anticipate that this client will exhibit? Increased heart rate and decreased blood pressure Decreased heart rate and increased blood pressure Increased heart rate and increased blood pressure Decreased heart rate and decreased blood pressure

d Rationale: Hypothermia decreases the heart rate and blood pressure, because the metabolic needs of the body are reduced with hypothermia. With fewer metabolic needs, the workload of the heart decreases, with corresponding drops in both heart rate and blood pressure.

an assistive personnel (AP) pulls an emergency call light in a client's room. Upon answering the light, the nurse finds a client who returned from surgery earlier in the day experiencing tachycardia and tachypnea. The client's blood pressure is 88/60 mm Hg. Which action should the nurse take first? Call the primary health care provider Check the hourly urine output Check the IV site for infiltration Place the client in a modified Trendelenburg position

d Rationale: The client is exhibiting signs/symptoms of shock and requires emergency intervention. The first action is to place the client in a modified Trendelenburg position (flat with the legs elevated) to increase blood return from the legs, which in turn increases venous return and subsequently the blood pressure. The nurse calls the primary health care provider, verifies the client's blood volume status by assessing urine output, and ensures that the IV infusion is proceeding without complications.

A client who is anxious about an impending surgery is at risk for respiratory alkalosis. For which signs/symptoms of respiratory alkalosis does the nurse assess this client? Drowsiness, headache, and tachypnea Disorientation and dyspnea Dysrhythmias and decreased respiratory rate and depth Tachypnea, dizziness, and paresthesias

d Rationale: The client who is anxious is at risk for respiratory alkalosis as a result of hyperventilation. The client is likely to exhibit tachypnea, dizziness, and paresthesias of the extremities. The client with respiratory acidosis would exhibit disorientation and dyspnea. The client with metabolic acidosis or alkalosis would exhibit signs/symptoms such as drowsiness, headache, and tachypnea and dysrhythmias and decreased respiratory rate and depth, respectively.

A client admitted to the hospital with a diagnosis of acute pancreatitis has blood drawn for several serum laboratory tests. Which value, noted by the nurse reviewing the results, would be expected in this client at this time? Total calcium (Ca2+) 9 mg/dL Potassium (K+) 4 mEq/L Hemoglobin (Hb) 15 G/100 mL 14 to 18 g/100 mL, males; 12 to 16 g/100 mL, females Serum amylase 395 units/L

d Rationale: The normal serum amylase range is 30 to 122 U/L (0.51 to 2.07 μkat/L). In acute pancreatitis, the amylase level is greatly increased; the level starts rising 3 to 6 hours after the onset of pain, peaks at about 24 hours, and returns to normal in 2 to 3 days after the onset of pain. Normal hemoglobin (Hb) level is 14 to 18 g/100 mL in males, and 12 to 16 g/100 mL in females; normal potassium (K+) is 3.5 to 4.5 mEq/L; and normal total calcium (Ca2+) is 8.5 to 10.5 mg/dL.

A nurse is preparing a client for transfer to the operating room. Which action should the nurse take in the care of this client at this time? Verifying that the client has not eaten for the last 24 hours Administering all daily medications Practicing postoperative breathing exercises Ensuring that the client has voided

d Rationale: The nurse should ensure that the client has voided if a Foley catheter is not in place. The nurse does not administer all daily medications just before sending a client to the operating room. Rather, the primary health care provider writes a specific prescription outlining which medications may be given with a sip of water. The client is usually prescribed to have nothing by mouth for 8 hours before surgery, not 24 hours. The time of transfer to the operating room is not the time to practice breathing exercises. This should have been done earlier.

A nurse provides information to a client who is scheduled for cardiac catheterization to rule out coronary occlusion. The nurse should provide which information to the client? The room is bright and well lit, and it is best to keep the eyes closed The procedure is performed in the operating room It is necessary to lie quietly on a hard x-ray table for about 4 hours The client may have feelings of warmth or flushing during the procedure

d Rationale: The nurse tells the client about to undergo cardiac catheterization room that the procedure is performed in a darkened room in the radiology department. A local anesthetic is used, so there is little or no pain with catheter insertion. The procedure may take as long as 2 hours, during which time the client may feel various sensations including a feeling of warmth or flushing, with catheter passage and dye injection. The x-ray table is hard and may be tilted periodically to obtain the best possible views.

A client who underwent preadmission testing 1 week before surgery had blood drawn for several serum laboratory studies. Which abnormal laboratory results should the nurse report to the surgeon's office? Select all that apply. Serum creatinine 0.8 mg/dL (70 μmol/L) Platelets 210× 103/μL (210 × 109/L) Sodium 141 mEq/L (141 mmol/L) Hematocrit 30% (0.30) Correct Hemoglobin 8.9 g/dL (89 g/L)

d, e Rationale: Routine screening tests include complete blood cell count, serum electrolyte analysis, coagulation studies, and serum creatinine tests. The complete blood cell count includes the hemoglobin and hematocrit analysis. All of these values are within their normal ranges except the hemoglobin and hematocrit. If a client has low hemoglobin and hematocrit levels, the surgery may be postponed by the surgeon. The normal hemoglobin level for a male ranges from 13.2 to 17.3 g/dL (132-173 g/L) and for a female, 11.7 to 15.5 g/dL (117-155 g/L). The normal hematocrit for a male ranges from 39% to 50% (0.39-0.50) and for a female, 35% to 47% (0.35-0.47).

A client has been given a diagnosis of multiple myeloma. Which result does the nurse reviewing the client's laboratory findings recognize as being specifically related to this diagnosis? Increased calcium level Decreased blood urea nitrogen (BUN) Decreased number of plasma cells in the bone marrow Increased white blood cell (WBC) count

a

A pelvic ultrasound is prescribed to evaluate a client's ovarian mass. What should the nurse giving pre-procedure instructions tell the client that is important to do before the procedure? Eat only a light breakfast Wear comfortable clothing and shoes Stop eating or drinking at midnight before the test Incorrect Drink 6 to 8 glasses of water without voiding

d Rationale: Pelvic ultrasound requires the ingestion of a large volume of water just before the procedure. A full bladder helps ensure that the bladder is easily visualized and not mistaken for a pelvic growth. A client undergoing abdominal (not pelvic) ultrasound may have to refrain from eating or drinking for several hours before the procedure.