NCLEX Questions-Week 7

A client who has undergone a barium enema is being readied for discharge. The nurse determines that the client has understood discharge instructions when the client makes which statement?

"I will be sure the barium passes and will watch for my stools to return to normal."

The nurse is attending a presentation created by a nursing student on the impact of lack of health insurance on the individual. The nurse determines the nursing student has a need for further teaching if the student makes which statement?

"Uninsured individuals are more likely to seek preventive care."

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The nurse reviews the laboratory results for the client's activated partial thromboplastin time (aPTT). Based on the result, the nurse anticipates that which action is needed? Laboratory Results Thromboplastin time (aPTT) 65 sec (30-40 sec)

Leaving the rate of the heparin infusion as is

The nurse is getting a postoperative client out of bed for the first time since surgery. The nurse raises the head of the bed, and the client complains of dizziness. Which action would the nurse take first?

Lower the head of the bed slowly until the dizziness is relieved.

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for?

Metabolic alkalosis

While giving care to a client with cervical cancer who has an internal cervical radiation implant, the nurse finds the implant in the bed. The nurse would take which initial action?

Pick up the implant with long-handled forceps and place it in a lead container.

The nurse is reading a computer printout of the results of a cerebrospinal fluid (CSF) analysis performed on an adult client who underwent lumbar puncture. The nurse knows that a reported value of 0 is normal for which substance in CSF?

Red blood cells

Which client is at risk for the development of a sodium level at 130 mEq/L? Laboratory Results Sodium 130 mEq/L (135-145 mEq/L)

The client who is taking diuretics

The nurse is assisting a client to ambulate when the client states that they are feeling faint and cannot stand. Which action would the nurse take to assist the client now?

The nurse would extend one leg to use to slide the client's body down to the floor.

The nurse is explaining the concept of a time-out in the perioperative area. Which statement best describes the purpose of a time-out?

To allow members of the surgical team a chance to verbally verify their agreement about the client's name, the surgical procedure, and the operative site

A client returns from the recovery room following an abdominal surgical procedure. Following the arrival of the client to the nursing unit, the nurse observes that the client has a patent airway. Which is the next nursing assessment?

Vital signs

The nurse is monitoring a group of clients for acid-base imbalances. Which clients are at highest risk for metabolic acidosis? Select all that apply.

-Client with pancreatitis -Malnourished client -Client with diabetes mellitus -Client with status epilepticus -Client with severe prolonged diarrhea

The nurse determines that which clients are at high risk for metabolic acidosis? Select all that apply.

-Clients with malnourishment -Clients with kidney failure -Clients with diabetes

A client is suspected of having a myocardial infarction. The nurse would expect elevations in which laboratory values to support the diagnosis? Select all that apply.

-Creatinine phosphokinase MB (CPK-MB) -Troponin I

A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse trying to enhance the client's respiratory status would avoid performing which actions? Select all that apply.

-Encouraging the client to breathe slowly and shallowly -Increasing the liter flow to 5 L per nasal cannula

The nurse is caring for a homebound older postoperative cardiovascular client. The client's child says to the nurse, "My parent has fallen out of bed three times." Which actions would the nurse reinforce to prevent falls? Select all that apply.

-Ensure that frequently used items are easily accessible. -Have the bedside stand and overbed tray table within reach. -Provide adequate lighting.

The nurse is preparing a client for surgery. Which would be components of the plan of care? Select all that apply.

-Instruct the client not to swallow water with oral hygiene on the morning of surgery. -Document that any medications the client was instructed to take before surgery are given.

The nurse is reading a client's urinalysis report. The nurse interprets which item found on the report to be considered abnormal? Select all that apply. Laboratory Results Color yellow Clarity clear pH 6 Protein positive Glucose negative Specific gravity 1.018 Leukocyte esterase positive Bilirubin negative Nitrites negative

-Leukocyte esterase positive -Positive protein

The nurse is assigned to care for a client who has just returned to the nursing unit following a renal biopsy. The nurse plans to do which actions to properly care for this client for the remainder of the shift? Select all that apply.

-Observe the urine and biopsy site for bleeding. -Test the urine for occult blood.

The nurse is informed of the arterial blood gas results of a client and notes the following: pH 7.45, Pco2 of 30 mm Hg, and HCO3 of 20 mEq/L. The nurse analyzes these results as indicating which condition? Laboratory Results pH 7.45 (7.35-7.45) Pco2 30 mm Hg (35-45 mm Hg) HCO3 20 mEq/L (21-28 mEq/L)

Respiratory alkalosis, compensated

A client has been diagnosed as having syndrome of inappropriate antidiuretic hormone (SIADH) secretion following cranial surgery. The nurse interprets that this complication is not resolving if which urine specific gravity measurement is obtained? Laboratory Results Urine specific gravity 1.032 (1.003-1.030)

1.032

The nurse is reviewing the laboratory results from the lumbar puncture performed on a client with a diagnosis of meningitis. Which findings are indicative of a bacterial infection? Select all that apply. Laboratory Results Lumbar protein 20 mg/dL (15-45 mg/dL) Glucose 72 mg/dL (50-75 mg/dL) WBC count 10 cells/mcL (0-5 cells/mcL) Red blood cells, Negative (Negative) CSF pressure 250 cm H2O (<20 cm H2O)

-White blood cell level -Cerebrospinal fluid (CSF) pressure

A client is admitted to the hospital with a diagnosis of malnutrition. The nurse is told that blood will be drawn to determine whether the client has a protein deficiency. Which laboratory data indicate that the client is experiencing a protein deficiency? Select all that apply. Laboratory Results Albumin 2.2 g/dL (3.5-5.0 g/dL) Calcium 10 mg/dL (9-10.5 mg/dL) Sodium 138 mEq/L (135-145 mEq/L) Transferrin 90 mg/dL (215-365 mg/L) Prealbumin 10 mg/dL (15-36 mg/dL)

-Transferrin level -Prealbumin level -Albumin level

The nurse is caring for a postoperative client who underwent a pelvic exenteration. The physician has changed the client's diet from nothing by mouth (NPO) to clear liquids. The nurse checks for which information before administering the clear liquids? Select all that apply.

-Whether the client has passed flatus -Presence of bowel sounds

Abdominal ultrasonography is prescribed for a client who is pregnant. The nurse provides information to the client regarding the procedure and makes which statement?

"You will be positioned on your back and turned slightly to one side with your head elevated."