Unit 2 Flashcards- NCLEX

A client is a lacto-vegetarian. Which food item should the nurse remove from the tray?

eggs

A client has a history of mild renal insufficiency. Which serum creatinine level should the nurse determine is consistent with this problem?

1.9 mg/dL- The normal serum creatinine level is 0.6 to 1.3 mg/dL. The client with mild renal insufficiency would have a slightly elevated level, which would be the value of 1.9 mg/dL. Creatinine levels of 3.5 mg/dL may be associated with acute kidney injury or chronic kidney disease.

A client with hepatic cirrhosis has been consuming a diet with optimal amounts of protein. The nurse determines that the client's consumption of dietary protein has been most effective if the total protein level is which value?

6.8 g/dL- The normal range for the protein level in the adult client is 6 to 8 g/dL, which makes the value of 6.8 g/dL the correct choice. The remaining options are all low levels and do not indicate that the diet has been most effective.

When reinforcing instructions to a client with acute diverticulitis, which should the nurse include?

Avoid whole-grain products.

A client having preadmission testing before surgery has blood drawn for the determination of serum electrolyte levels. The nurse determines that which result warrants a call to the health care provider by the nurse?

sodium, 148 mEq/L-The normal serum electrolyte ranges for adults are as follows: sodium, 135 to 145 mEq/L; potassium, 3.5 to 5.0 mEq/L; chloride, 98 to 107 mEq/L; and bicarbonate (venous), 22 to 29 mEq/L.

A client is scheduled for blood to be drawn from the radial artery for an arterial blood gas (ABG) determination. The nurse assists with performing Allen's test before drawing the blood to determine the adequacy of which?

ulnar circulation- if not assessed could result in ischemic injury to hand.

The nurse is told that the laboratory result for the serum digoxin level is 2.4 ng/mL. Which action should the nurse take?

withhold the med- therapeutic range for dig is 0.5 to 2 ng/mL.

A client with diabetes mellitus has a blood sample drawn for the determination of a fasting blood glucose level. When reviewing the client's results, the nurse determines that which requires a call to the health care provider for intervention?

240 mg/dL- The normal fasting blood glucose level is 70 to 100 mg/dL in the adult client without diabetes and 70 to 130 in the client with diabetes. Values above the normal range should be evaluated to determine if further intervention is needed. The most critical value is 240 mg/dL.

A client with a history of cardiac disease is scheduled for a dose of furosemide (Lasix). Which serum potassium level warrants a call to the health care provider by the nurse before administering the furosemide?

3.2 mEq/L- to a client with a low potassium level and a cardiac history could precipitate ventricular dysrhythmias in the client.

A client arrives in the emergency department complaining of chest pain that began 4 hours ago. A troponin T blood specimen is obtained, and the results indicate a level of 0.6 ng/mL. How should the nurse correctly interpret these results?

The level is indicative of a myocardial infarction- The troponins function together in the contractile apparatus for striated muscle in the skeletal muscle and the myocardium. Increased amounts of troponins are released into the bloodstream when an infarction causes damage to the myocardium. A troponin T level greater than 0.1 to 0.2 ng/mL is consistent with a myocardial infarction. A normal troponin I level is less than 0.6 ng/mL,

The nursing student is preparing a conference on Freud's psychosexual stages of development, specifically the anal stage. Which appropriately relates to this stage?

beginning of toilet training

Which is the most appropriate location for assessing the pulse of an infant who is less than 1 year old?

brachial

A client with heart disease is instructed regarding a low-fat diet. The nurse determines that the client understands the diet if the client states to avoid which food item?

cheese-high in fat

The medication prescribed is heparin sodium 650 units subcutaneously, every 12 hours. The medication vial reads heparin sodium 1000 units/mL. The nurse prepares how many milliliters to administer one dose? Fill in the blank.

desired * mL = mL per dose 650 units * 1mL = 0.65 mL per 1000 units

A client has the following laboratory values: a pH of 7.55, an HCO3- level of 22 mm Hg, and a PCo2 of 30 mm Hg. Which action should the nurse take?

encourage client to slow down breathing.

A client is having problems with blood clotting. Which food item should the nurse encourage the client to eat?

green, leafy veggies

The nurse is caring for a client with severe diarrhea. The nurse monitors the client closely, understanding that this client is at risk for developing which acid-base disorder?

metabolic acidosis- intestinal secretions high is bicarbonate are being lost.

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation?

metabolic alkalosis- loss of gastric fluid or vomiting causes fluid loss resulting in alkalotic condition.

The registered nurse reviews the results of the arterial blood gases with the licensed practical nurse (LPN) and tells the LPN that the client is experiencing respiratory acidosis. The LPN should expect to note which on the laboratory result report?

pH 7.25, PCO2 50 mm Hg

The nurse monitors the postoperative client frequently, knowing that accumulated secretions can lead to which problem?

pneumonia