NCLEX-PN Review

The nurse is educating a new nurse about mass casualty events (disasters). Which statement by the new nurse indicates a need for further teaching? Select all that apply 1) "An event is termed a mass casualty when it overwhelms local medical capabilities" 2) "Mass casualty events do not require an increase in the number of staff that are needed." 3) "A mass casualty event occurs only within the health care facility and could endanger staff." 4) "A mass casualty event occurs if a fight between visitors occurs in the emergency department." 5) "Mass casualty events may require the collaboration of many local agencies to handle the situation."

2,3,4; Mass casualty events overwhelm local medical capabilities and may require collaboration of multiple agencies and health care facilities to handle the crisis. This type of event can occur in the facility or out. Fights in the emergency department are not termed mass casualty events but are agency security and local enforcement issues. Mass casualty events almost always require an increase in staffing to ensure safe patient care.

The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L. The nurse understands that a potassium value at this level would be noted with which condition? 1) Diarrhea 2) Traumatic burn 3) Cushing's syndrome 4) Overuse of laxatives

2; A serum potassium level that exceeds 5.0 mEq/L is hyperkalemia. Clients who experience the cellular shifting of potassium, as in the early stages of massive cell destruction (ex: trauma, burns, sepsis, or metabolic/respiratory acidosis) are at risk for hyperkalemia.

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for fluid volume deficit? 1) The client with cirrhosis 2) The client with a colostomy 3) The client with heart failure (HF) 4) The client with decreased kidney function

2; Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, ileostomy, and colostomy. A client with cirrhosis, HF, or decreased kidney function is at risk for fluid volume excess.

The nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed, and the serum calcium level is 12.0 mg/dL. Based on this laboratory value, the nurse should take which action? 1) Document the value in the client's record. 2) Inform the RN of the laboratory value. 3) Place the laboratory result form in the client's record. 4) Reassure the client that the laboratory result is normal.

2; Normal serum calcium level = 8.6-10.0 mg/dL. The client is experiencing hypercalcemia and the nurse would inform the RN of the laboratory value. Because the client is experiencing hypercalcemia, the remaining options are incorrect actions.

The nurse finds the client lying on the floor. The nurse calls the RN, who checks the client and then calls the nursing supervisor and the health care provider to inform them of the occurrence. The nurse completes the incident report for which purpose? 1) Providing clients with necessary stabilizing treatments. 2) A method of promoting quality care and risk management. 3) Determining the effectiveness of interventions in relation to outcomes. 4) The appropriate method of reporting to local, state, and federal agencies.

2; Proper documentation of unusual occurrences, incidents, accidents, and the nursing actions taken as a result of the occurrence are internal to the institution. Documentation on the incident report allows the nurse and administration to review the quality of care and determine any potential risks present.

The nurse is planning the client assignments for the day. Which is the most appropriate assignment for the unlicensed assistive personnel (UAP)? 1) A client who requires wound irrigation 2) A client who requires frequent ambulation 3) A client who is receiving continuous tube feedings 4) A client who requires frequent vital signs after a cardiac catheterization

2; The most appropriate assignment for the UAP would be to care for the client who requires frequent ambulation. The UAP is skilled in this task. (Ambulation = walking)

A client is diagnosed with cancer and is told that surgery followed by chemotherapy will be necessary. The client states to the nurse, "I have read a lot about complementary therapies. Do you think I should try any?" The nurse should respond by making which appropriate statement? 1) "I would try anything that I could if I had cancer." 2) "You need to ask your health care provider about it." 3) "No, because it will interact with the chemotherapy." 4) "Let's talk more about the different forms of complementary therapies."

4; Although the HCP should approve the use of a complementary therapy, it is important for the nurse to explore the complementary therapies first with the client, which would eliminate option 2. Options 1 and 3 are inappropriate.

The nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L. Which should the nurse observe for on the cardiac monitor as a result of this laboratory value? 1) ST elevation 2) Peaked P waves 3) Prominent U waves 4) Narrow, peaked T waves

4; A serum potassium level of 5.4 mEq/L is indicative of hyperkalemia. Cardiac changes include a wide,flat P wave, a prolonged PR interval, a widened QRS complex, and narrow, peaked T waves.

The nurse employed in an emergency department is assigned to assist with the triage of clients arriving to the emergency department. The nurse should assign priority to which client? 1) A client complaining of muscle aches, a headache, and malaise 2) A client who twisted her ankle when she fell while in-line skating 3) A client with a minor laceration on the index finger sustained while cutting an eggplant 4) A client with chest pain who states that he just ate pizza that was made with a very spicy sauce

4; Clients with chest pain, trauma, severe respiratory distress, cardiac arrest, limb amputation, or acute neurological deficits, and those who sustained a chemical splash to the eyes are classified as an emergent, and are 1st priority. Clients with conditions such as simple fractures, asthma without respiratory distress, fever, hypertension, abdominal pain, or renal stones have urgent needs, and these clients are classified as 2nd priority. Clients with conditions such as minor lacerations, sprains, or cold symptoms are classified as non-urgent, and they are 3rd priority.

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at the least likely risk for the development of third-spacing? 1) The client with sepsis 2) The client with cirrhosis 3) The client with kidney failure 4) The client with diabetes mellitus

4; Fluid that shifts into the interstitial spaces and remains there is third-space fluid. Common sites include: abdomen, pleural cavity, peritoneal cavity, and pericardial sac. It is useless because it does not circulate to provide nutrients. Risk factors include liver/kidney disease, major surgery, malignancy, malabsorption syndrome, etc.

The nurse reviews electrolyte valves and notes a sodium level of 130 mEq/L. The nurse expects that this sodium level would be noted in a client with which condition? 1) The client with watery diarrhea 2) The client with diabetes insipidus (DI) 3) The client with an inadequate daily water intake 4) The client with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH)

4; Hyponatremia is a serum sodium level less than 135 mEq/L. Hyponatremia can occur secondary to SIADH. The client with an inadequate daily water intake, watery diarrhea, or diabetes insipidus is at risk for hypernatremia.

The nurse who is caring for a client with kidney failure notes that the client is dyspneic, and crackles are heard on auscultation of the lungs. Which additional signs/symptoms should the nurse expect to note in this client? 1) Rapid weight loss 2) Flat hand and neck veins 3) A weak and thready pulse 4) An increase in blood pressure

4; Impaired cardiac or kidney function can result in fluid volume excess. Findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure, a bounding pulse, an elevated central venous pressure, weight gain, edema, neck and hand vein distention, an altered level of consciousness, and a decreased hematocrit level.

The nurse is told that the blood gas results indicate a pH of 7.50 and a PCO2 of 32 mm Hg. The nurse determines that these results are indicative of which acid-base disturbance? 1) Metabolic acidosis 2) Metabolic alkalosis 3) Respiratory acidosis 4) Respiratory alkalosis

4; Normal pH is 7.35 to 7.45. In a respiratory condition, an opposite relationship will be seen between the pH and the PCO2, as is seen in the correct option. In an alkalotic condition, the pH is increased. In an acidotic condition, the pH is decreased so both metabolic acidosis and respiratory acidosis can be eliminated. Metabolic alkalosis can also be eliminated because both pH and HCO3- are increased above normal values in this condition.

The nurse observes that a client received pain medication an hour ago from another nurse, but the client still has severe pain. The nurse has previously observed this same occurrence. Based on the nurse practice act, the observing nurse should plan to take which action? 1) Report the information to the police. 2) Call the impaired nurse organization. 3) Talk with the nurse who gave the medication. 4) Report the information to a nursing supervisor.

4; Nurse practice acts require reporting the suspicion of impaired nurses. The state board of nursing has jurisdiction over the practice of nursing and may develop plans for treatment and supervision. This suspicion needs to be reported to the nursing supervisor, who will then report to the board of nursing.

An unconscious client, bleeding profusely, is brought to the emergency department after a serious accident. Surgery is required immediately to save the client's life. With regard to informed consent for the surgical procedure, which is the best action? 1) Call the nursing supervisor to initiate a court order for the surgical procedure. 2) Try calling the client's spouse to obtain telephone consent before the surgical procedure. 3) Ask the friend who accompanied the client to the emergency department to sign the consent form. 4) Transport the client to the operating department immediately, as required by the health care provider, without obtaining an informed consent.

4; Only 2 instances in which the informed consent of an adult client is not needed: when an emergency is present and delaying treatment for the purpose of obtaining consent would result in injury or death to the client, and when the client waives the right to give consent.

The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional signs/symptoms should the nurse expect to note in this client if hyponatremia is present? 1) Intense thirst 2) Slow bounding pulse 3) Dry mucous membranes 4) Postural blood pressure changes

4; Postural blood pressure changes occur in the client with hyponatremia. Intense thirst and dry mucous membranes are seen in clients with hypernatremia. A slow, bounding pulse is not indicative of hyponatremia. In a client with hyponatremia, a rapid, thready pulse is noted.

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? 1) Metabolic acidosis 2) Metabolic alkalosis 3) Respiratory acidosis 4) Respiratory alkalosis

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The nurse has delegated several nursing tasks to staff members. Which is the nurse's primary responsibility after the delegation of the tasks? 1) Document that the task was completed 2) Assign the tasks that were not completed to the next nursing shift 3) Allow each staff member to make judgement when performing the tasks. 4) Perform follow-up with each staff member regarding the performance and outcome of the task.

4; Ultimate responsibility for a task lies with the person who delegated it. Therefore, it is the nurse's responsibility to follow up with each staff member regarding he performance of the task and the outcomes.

When caring for the following groups of clients, who does the nurse determine is at risk for development of metabolic alkalosis? Select all that apply. 1) Client with emphysema. 2) Client who is hyperventilating. 3) Client with chronic kidney disease. 4) Client who has been vomiting for two days. 5) Client receiving furosemide (Lasix) 40 mg daily 6) Client admitted with acetylsalicylic acid (aspirin) overdose

1, 3, 4, 5, 6

The nurse consults with a dietician regarding the dietary preferences of an Asian-American client. Which food should the nurse suggest to include in the diet plan? 1) Rice 2) Fruits 3) Red meat 4) Fried foods

1; Asian-American food preferences include raw fish, rice, and soy sauce.

The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which signs/symptoms would be an indication of this electrolyte imbalance? 1) Twitching 2) Positive Trousseau's sign 3) Hyperactive bowl sounds 4) Generalized muscle weakness

4; Generalized muscle weakness is seen in clients with hypercalcemia. Twitching, positive Trousseau's sign, and hyperactive bowel sounds are signs of hypocalcemia.

The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding should the nurse expect to note as a result of this long-term use? 1) Gurgling respirations 2) Increased blood pressure 3) Decreased hematocrit level 4) Increased specific gravity of the urine

4; Clients taking diuretics on a long-term basis are at risk for fluid volume deficit. Increased specific gravity of the urine is a finding of fluid volume deficit. The rest refer to fluid volume excess.

The nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse should monitor the client for which acid-base imbalance? 1) Metabolic acidosis 2) Metabolic alkalosis 3) Respiratory acidosis 4) Respiratory alkalosis

2

The nurse is caring for a client with diabetic ketoacidosis and observes that the client is experiencing abnormally deep, regular, rapid respirations. How should the nurse correctly document this observation in the medical record? 1) Apnea observed 2) Bradypnea noted 3) Cheyne Stokes demonstrated 4) Kussmaul's respirations observed

3

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? 1) Ulnar circulation 2) Cartoid circulation 3) Femoral circulation 4) Brachial circulation

1; Before performing a radial puncture to obtain an arterial specimen for ABGs, Allen's test should be performed to determine adequate ulnar (ulna, on the pinky side) circulation. Failure to assess collateral circulation could result in severe ischemic injury to the hand if damage to the radial artery occurs with arterial puncture. The remaining options are not associated with this test.

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse check first? 1) A client on a ventilator 2) A client in skeletal traction 3) A postoperative client preparing for discharge 4) A client admitted on the previous shift who has a diagnosis of gastroenteritis

1; The airway is always a priority, and the nurse first checks the client on a ventilator. The clients described in operations 2,3, and 4 have needs that would be identified as intermediate priorities.

The nurse is attending an agency orientation meeting about the nursing model of practice implemented in the facility. The nurse is told that the nursing model is a team nursing approach. The nurse understands that which is a characteristic of this type of nursing model of practice? 1) A task approach method is used to provide care to clients. 2) Managed care concepts and tools are used when providing patient care. 3) Nursing staff are led by the nurse when providing care to a group of clients. 4) A single registered nurse is responsible for providing nursing care to a group of clients.

3; In team nursing, nursing personnel are led by the nurse when providing care to a group of clients. Option 1 identifies functional nursing. Option 2 identifies a component of care management. Option 4 identifies primary nursing.

A nurse lawyer provides an education session to the nursing staff regarding client rights. The nurse asks the lawyer to describe an example that may relate to the invasion of client privacy. Which nursing action indicates a violation of client privacy? 1) Threatening to place a client in restraints. 2) Performing a surgical procedure without consent. 3) Taking photographs of the client without consent. 4) Telling the client that he or she cannot leave the hospital.

3; Invasion of privacy takes place when an individual's private affairs are intruded on unreasonably.

A client experiences a cardiac arrest. The nurse leader quickly responds to the emergency and assigns clearly defined tasks to the work group. In this situation, the nurse is implementing which leadership style? 1) Autocratic 2) Situational 3) Democratic 4) Laissez-faire

1; Autocratic leadership is an approach in which the leader retains all authority. Effective in a crisis. Leader assigns clearly defined tasks and establishes one-way communication and makes decisions. Situational leadership incorporates the leader's style, maturity of work group, and situation at hand. Democratic leadership is a people-centered approach. Laissez-faire leadership is a permissive style in which the leader gives up control and delegates all decision making to work group.

The nurse enters a client's room and notes that the client's lawyer is present and that the client is preparing a living will. The living will requires that the client's signature be witnessed, and the client asks the nurse to witness the signature. Which is the appropriate nursing action? 1) Decline to sign the will. 2) Sign the will as a witness to the signature only. 3) Call the hospital lawyer before signing the will. 4) Sign the will, clearly identifying credentials and employment agency.

1; Living wills are required to be in writing and signed by the client. The client's signature either must be witnesses by specified individuals or notarized. Many states prohibit any employee from being a witness, including the nurse in a facility where a client is receiving care.

An older woman is brought to the emergency department. When caring for the client, the nurse notes old and new ecchymotic areas on both of the client's arms and buttocks. The nurse asks the client how the bruises were sustained. The client, although reluctant, tells the nurse in confidence that her daughter frequently hits her if she gets in the way. Which is the appropriate nursing response? 1) "I have a legal obligation to report this type of abuse." 2) "I promise I won't tell anyone, but let's see what we can do about this." 3) "Let's talk about ways that will prevent your daughter from hitting you." 4) "This should not be happening. If it happens again, you must call the emergency department."

1; Nurse must report situations related to child, older adult abuse, and other types of abuse, depending on state laws; gunshot wounds, stabbings; and certain infectious diseases.

The nurse is recording a nursing hands-off (end-of-shift) report for a client. Which information needs to be included? 1) As-needed medications given that shift 2) Normal vital signs that have been normal since admission 3) All of the tests and treatments the client has had since admission 4) Total number of scheduled medications that the client received on that shift

1; The hands-off report needs to include the as-needed medications given or therapies performed during the past 24 hours, including the client's response to them.

The nurse is planning to reinforce nutrition instructions to an African-American client. When reviewing the plan, the nurse is aware that which food is a common dietary practice of clients with African-American heritage? 1) Raw fish 2) Red meat 3) Fried foods 4) Rice as the basis for all meals

3; African-American food preferences include chicken, pork, greens, rice, and friend foods. Asian Americans eat raw fish, rice, and soy sauce. Hispanic Americans prefer beans, fried foods, spicy foods, chili, carbonated beverages. European Americans prefer carbohydrates and red meat. African-American culture is known for being at risk for hypertension and coronary artery disease.

The nurse is caring for a group of clients who are taking herbal medications at home. Which client should be given instructions in regard to avoiding the use of herbal medications? 1) A 60-year-old male client with rhinitis 2) A 24-year-old male client with a lower back injury 3) A 10-year-old female with a urinary tract infection 4) A 45-year-old female client with a history of migraine headaches

3; Children should not be given herbal therapies, especially in the home and without professional supervision.

An antihypertensive medication has been prescribed for a client with hypertension. The client tells the nurse that she would like to take an herbal substitute to help lower her blood pressure. Which statement by the nurse is most important to provide the client? 1) "Herbal substances are not safe and should never be used." 2) "I will teach you how to take your blood pressure so that it can be monitored closely." 3) "You will need to talk to your health care provider (HCP) before using an herbal substance." 4) "If you take an herbal substance, you will need to have your blood pressure checked frequently."

3; Although herbal substances may have some beneficial effects, not all herbs are safe to use. Clients who are being treated with conventional medication therapy should be advised to avoid herbal substances with similar pharmacological effects, because the combination may lead to an excessive reaction or unknown interaction effects. Therefore, the nurse would advise the client to discuss the use of the herbal substance with the HCP.

The nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL. Which prescribed medication should the nurse prepare to assist in administering to the client? 1) Calcium chloride 2) Calcium gluconate 3) Calcitonin (Miacalcin) 4) Large dose of vitamin D

3; The normal serum calcium level = 8.6 to 10.0 mg/dL. Therefore this is hypercalcemia. Calcium gluconate and calcium chloride are medications used for the treatment of tetany, which occurs as a result of acute hypocalcemia. In hypercalcemia, large doses of vitamin D need to be avoided. Calcitonin, a thyroid hormone, decreases the plasma calcium level by inhibiting bone resorption and lowering the serum calcium concentration.

A Hispanic-American mother brings her child to the clinic for an examination. Which is most important when gathering data about the child? 1) Avoiding eye contact 2) Using body language only 3) Avoid speaking to the child 4) Touching the child during the examination

4; In the Hispanic-American culture, eye behavior is significant. It is believed that the "bad/evil eye" can be given to a child if a person looks at and admires a child without touching the child. Therefore, touching the child during the examination is very important.

The nurse is assisting with collecting data from an African-American client admitted to the ambulatory care unit who is scheduled for a hernia repair. Which information about the client is of least priority during the data collection? 1) Respiratory 2) Psychological 3) Neurological 4) Cardiovascular

2; In the African-American culture, it is considered intrusive to ask personal questions during the initial contact or meeting. Respiratory, neurological, and cardiovascular data include physiological assessments, which would be the priority.

The client asks the nurse about various herbal therapies available for the treatment of insomnia. The nurse should encourage the client to discuss the use of which product with the health care provider? 1) Garlic 2) Valerian 3) Lavender 4) Glucosamine

2; Valerian has been used to treat insomnia, hyperactivity, and stress. It has also been used to treat nervous disorders such as anxiety and restlessness. Garlic is used as an antioxidant and to lower cholesterol levels. Lavender is used as an antiseptic and fragrance for a mild sedative effect. Glucosamine is an amino acid that assists with the synthesis of cartilage.

The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse should tell the client that which food is least likely to contain calcium? 1) Milk 2) Butter 3) Spinach 4) Collard greens

2; Butter comes from milk fat and does not contain significant amounts of calcium. Milk, spinach, and collard greens are calcium-containing foods and should be avoided by the client on a calcium-restricted diet.

The nurse is caring for a client with respiratory insufficiency. The arterial blood gas results indicate a pH of 7.50 and a PCO2 of 30 mm Hg, and the nurse is told that the client is experiencing respiratory alkalosis. Which additional laboratory value should the nurse expect to note? 1) A sodium level of 145 mEq/L 2) A potassium level of 3.2 mEq/L 3) A magnesium level of 2.4 mg/dL 4) A phosphorus level of 4.0 mg/dL

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Which is a recommended guideline for safe computerized charting? 1) Passwords to the computer system should only be changed if lost. 2) Computer terminals may be left unattended during client-care activities. 3) Accidental deletions from the computerized file need to be reported to the nursing manager or supervisor. 4) Copies of printouts from computerized files should be kept on a clipboard at the nurses' station for other nurses to access.

3; After any inadvertent deletions of permanent computerized records, the nurse should type an explanation into the computer file with the date, time, and his or her initials. The nurse should also contact the nursing manager or supervisor with a written explanation of the situation.

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit? 1) The client with Addison's disease 2) The client with metabolic acidosis 3) The client with intestinal obstruction 4) The client receiving nasogastric suction

4; Potassium-rich gastrointestinal fluids are lost through GI suction, which places the client at risk for hypokalemia. The client with intestinal obstruction, Addison's disease, and metabolic acidosis is at risk for hyperkalemia.

The nurse is assigned to care for four clients. When planning client rounds, which client should the nurse collect data from first? 1) A client scheduled for a chest x-ray. 2) A client requiring daily dressing changes. 3) A postoperative client preparing for discharge. 4) A client receiving oxygen who is having difficulty breathing.

4; The airway is always a priority, the nurse would attend to the client who has been experiencing an airway problem first. The clients described in options 1,2,3 would have intermediate priority.

A nursing student is asked to identify the practices and the beliefs of the Amish society. Which should the student identify? Select all that apply. 1) Many choose not to have health insurance. 2) They believe that health is a gift from God. 3) The authority of women is equal to that of men. 4) They remain secluded and avoid helping others. 5) They use both traditional and alternative health care, such as healers, herbs, and massage. 6) Funerals are conducted in the home without an eulogy, flower decorations, or any other display. Caskets are plain and simple, without adornment.

1,2,5,6; The Amish society maintains a culture that is distinct and separate from the non-Amish society, and some members generally remain separate from the rest of the world, both physically and socially. The authority of women and men are unequal. Members value living simply, and they may choose to avoid technology, such as electricity and cars. They highly value responsibility and helping others. They use traditional health care and alternative health care. They believe that health is a gift from God but that clean living and a balanced diet help maintain it. They may choose not to have health insurance and instead maintain mutual aid funds for those members who need help with medical costs. Funerals are conducted in the home, simply. Women are usually buried in their bridal dresses at death.

A client has the following laboratory values: a pH of 7.55, and HCO3- level of 22 mm Hg, and a PCO2 of 30 mm Hg. Which action should the nurse taste? 1) Perform Allen's test. 2) Prepare the client for dialysis. 3) Administer insulin as prescribed. 4) Encourage the client to slow down breathing.

4; The client is in respiratory alkalosis based on the laboratory results of a high pH and a low PCO2 level. Interventions for respiratory alkalosis are the voluntary holding of breath or slowed breathing and the re-breathing of exhaled CO2 by methods such as using a paper bag or a re-breathing mask as prescribed. Performing Allen's test would be incorrect, because the blood specimen has already been drawn, and the laboratory results have been completed. Dialysis and insulin administration are interventions for metabolic acidosis.

A client has died, and the nurse asks a family member about the funeral arrangements. The family member refuses to discuss the issue. Which is the appropriate nursing action? 1) Show acceptance of feelings. 2) Provide information needed for decision making. 3) Suggest a referral to a mental health professional. 4) Remain with the family member without discussing funeral arrangements.

4; The family member is exhibiting the first stage of grief (denial) and the nurse should remain with the family member.

The nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL. The nurse understands that which condition would cause this serum calcium level? 1) Prolonged bed rest 2) Adrenal insufficiency 3) Hyperparathyroidism 4) Excessive ingestion of vitamin D

1; The normal serum calcium level = 8.6 to 10 mg/dL. This client has hypocalcemia. Although immobilization can initially cause hypercalcemia, the long term effect of prolonged bed rest is hypocalcemia. The rest refer to hypercalcemia.

The nurse employed in a long-term care facility is planning the client assignments for the shift. Which client should the nurse assign to the unlicensed assistive personnel (UAP)? 1) A client who requires a 24-hour urine collection 2) A client who requires twice-daily dressing changes 3) A client who is on a bowel management program and requires rectal suppositories and a daily enema 4) A client with diabetes mellitus who requires daily insulin and the reinforcement of dietary measures

1; The nurse must determine the most appropriate assignment on the basis of the skills of the staff member and the needs of the client. A 24-hour urine collection is a task that the UAP is skilled in. Others are for a licensed nurse.

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? 1) Metabolic acidosis 2) Metabolic alkalosis 3) Respiratory acidosis 4) Respiratory alkalosis

2

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? 1) pH 7.50, PCO2 52 mm Hg 2) pH 7.35, PCO2 40 mm Hg 3) pH 7.25, PCO2 50 mm Hg 4) pH 7.50, PCO2 30 mm Hg

3

The nurse is reading the HCP's progress notes in the client's record and sees that the HCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss? 1) Client with a draining wound 2) Client with a urinary catheter 3) Client with a fast respiratory rate 4) Client with a nasogastric tube to low suction

3; Sensible losses are those that the person is aware of, such as those that occur through wound drainage, GI tract losses, and urination. Insensible losses may occur without the person's awareness. Insensible losses occur daily throughout the skin and lungs.

The LPN enters a client's room and finds the client sitting on the floor. The LPN calls the RN, who checks the client thoroughly and then assists the client back into bed. The LPN completes an incident report, and the nursing supervisor and health care provider (HCP) are notified of the incident. Which is the next nursing action regarding the incident? 1) Place the incident report in the client's chart. 2) Make a copy of the incident report for the HCP. 3) Document a complete entry in the client's record concerning this incident. 4) Document in the client's record that an incident report has been completed.

3; The incident report is confidential and privileged information, and it should not be copied, placed in the chart, or have any reference made to it in the client's record. The incident report is not a substitute for a complete entry in the client's record concerning the incident.

The nurse is preparing to assist a client of Orthodox Jewish faith with eating lunch. A kosher meal is delivered to the client. Which nursing action is appropriate when assisting the client with the meal? 1) Unwrapping the eating utensils for the client 2) Replacing the plastic utensils with metal utensils 3) Carefully transferring food from the paper plates to glass plates 4) Allowing the client to unwrap the utensils and prepare his own meal for eating

4; Kosher meals arrive on paper plates and with plastic utensils sealed. Health care providers should not unwrap the utensils of transfer the food to another serving dish. Although the nurse may want to be helpful in assisting the client with the meal, the only appropriate option is option 4.

The nurse arrives at work and is told to report (float) to the pediatric unit for the day because the unit is understaffed and needs additional nurses to care for the clients. The nurse has never worked in the pediatric unit. Which is the appropriate nursing action? 1) Call the hospital lawyer. 2) Call the nursing supervisor. 3) Refuse to float to the pediatric unit. 4) Report to the pediatric unit and identify tasks that can be safely performed.

4; Floating is an acceptable legal practice used by hospitals to solve their understaffing problems. Legally the nurse cannot refuse to float unless a union contact guarantees that the nurse can only work in a specified area or the nurse can prove a lack of knowledge for the performance of assigned tasks. When faced with this situation, the nurse should identify potential areas of harm to the client.