NCLEX practice #1
A client diagnosed with hypernatremia needs fluid volume replacement. What intravenous solution would be the safest for the nurse to administer?
0.45% sodium chloride Explanation: A hypotonic solution (half-strength saline) is the solution of choice and considered safer than 5% dextrose in water because it allows a gradual reduction in the serum sodium level, thereby decreasing the risk of cerebral edema. An isotonic solution (0.9%) is not desirable as a supplement because it provides Na and CL.
The nurse at the beginning of the evening shift in the emergency department receives a report at 1900 on the following clients. Which client would the nurse assess first?
An 86-year-old with COPD who arrived on the floor 30 minutes ago and is a direct admit from the doctor's office
A nurse is caring for a client with osteomyelitis. What complication should the nurse consider that the client is at risk to develop?
Bone abscess formation
A patient prescribed a medication for hypertension started taking it 3 days ago and arrives in the emergency department with an edematous face and tongue and having a difficult time speaking. What medication is the nurse aware of that may produce this type of side effect?
Enalapril (Vasotec)
A client with a right below-the-knee amputation is being transferred from the postanesthesia care unit to a medical-surgical unit. What is the highest priority nursing intervention by the receiving nurse?
Ensure that a large tourniquet is in the room. Explanation:The patient with an amputation is at risk for hemorrhage. A tourniquet should be placed in plain sight for use if the patient hemorrhages. Documenting the receiving report is important, but is not the highest priority. The nurse may delegate to unlicensed assistive personnel (UAP) the job of gathering more pillows for positioning, but this is not the highest priority. The nurse will need to review the physician's orders for pain medication but, again, this is not the highest priority because any patient is hemorrhaging by the patient needs to be addressed first.
The nurse is educating a group of nursing students about COVID-19 and risk for cerebrovascular disorders. The nurse educator notes that COVID-19 has shown to increase which condition?
Ischemic stroke
To obtain information about the chief report and medical history of an older client, the nurse asks the client about any medication history. Why is obtaining a medication history important?
It may indicate multiple medications taken by the client.
A nurse is assessing a patient's ability to give informed voluntary consent for genetic testing. Which of the following would the nurse identify as interfering with this ability? Select all that apply.
Language barrier Cognitive deficits Opioid analgesic use Hearing deficits
After being in remission from Hodgkin's disease for 18 months, a client develops a fever of unknown origin. A healthcare provider orders a liver biopsy to rule out advancing Hodgkin's disease and infection. Twenty-four hours after the biopsy, the client has a fever, complains of severe abdominal pain, and seems increasingly confused. What should the nurse suspect?Normal postprocedural pain, with a change in the level of consciousness resulting from the pre-existing fever
Peritonitis from bleeding in the liver caused by the liver biopsy
A young man with a diagnosis of hemophilia A has been brought to emergency department after suffering a workplace accident resulting in bleeding. Rapid assessment has revealed the source of the client's bleeding and established that his vital signs are stable. What should be the nurse's next action?
Prepare for the administration of factor VIII.
