nclex 2021 must pass

A nurse is caring for a client who is on bed rest following admission to the hospital two days ago with a diagnosis of new onset heart failure. While evaluating the client's progress, what assessment findings would indicate to the nurse that treatment has been effective? 1. CVP 6 mmHg 2. 3.8 kg weight loss in 24 hours 3. Pink, frothy sputum 4. S3 heart sound 5. Urinary output 320 mL/8 hrs 6. Dyspnea on exertion

1,2&5

The nurse is caring for a client 8 hours post colectomy who is receiving 40% humidified oxygen. ABG results are: pH= 7.30, pO2= 91, pCO2= 50, HCO3= 24. Based on this information, which nursing action should the nurse initiate? 1. Reposition the client every 2 hours. 2. Request respiratory therapy to perform postural drainage and percussion. 3. Increase oxygen percentage. 4. Initiate incentive spirometry. 5. Assess mental status.

1,4 &5

What should the nurse monitor for when caring for a client receiving an IV infusion of 5% Normal Saline? 1. Hypotension 2. Fluid volume deficit 3. Hyponatremia 4. Phlebitis

4

A nurse is assessing a client who is one day post thyroidectomy and identifies an arrhythmia on auscultation. While taking the blood pressure, the nurse notices the client's hand starts to tremble. What interventions should the nurse initiate? 1. Administer magnesium sulfate IV 2. Continuous cardiac monitoring 3. Draw blood for phosphorus level 4. Initiate seizure precautions 5. Prepare to send client to surgery

2,3 &4

What clinical manifestation does the nurse expect to see in a client suspected of having hypercalcemia? 1. Tachycardia 2. Positive Chvostek 3. Lethargy 4. Tachypnea 5. Decreased deep tendon reflexes

3 & 5

An intravenous infusion of 5% dextrose in water is prescribed at a rate of 1000 mL in 8 hours. The tubing has a drop factor of 15. How many drops per minute (gtts/min) are delivered? Round your answer to the nearest whole number.

31

How should the nurse interpret the arterial blood gas (ABG) results of a client admitted with dehydration? ABGs pH - 7.48 PaCO2 - 30 HCO3 - 23

4&5

A client has been admitted with a diagnosis of septic shock and has been successfully intubated.The nurse performs and documents a rapid assessment. Which action is most important for the nurse to perform? Blood Pressure92/54 mmHgHeart Rate116 bpmRespiratory Rate22 breaths/minTemperature103oF (39.4oC)Oxygen Saturation91% Heart tones irregular, distant. Face flushed and warm. Extremities cool and mottled. Radial pulses faintly palpable. Pedal pulses non-palpable. Denies chest pain. Endotracheal tube taped in place via oropharynx. Right anterior and posterior lung sounds clear. Unable to hear left lung sounds. Grimaces with light abdominal palpation over pelvic bone. Urine amber and cloudy with red streaks. 100 mL urine output in foley catheter bag. Opens eyes and moves to command. Pupils equal, round, and react to light. 1. Pull the ET tube back until breath sounds are heard bilaterally. 2. Start an IV of Normal Saline at 125 mL/hr. 3. Administer acetaminaphen 500 mg rectally. 4. Obtain urine for culture and sensitivity.

1

Based on the results of the arterial blood gases (ABGs), what imbalance does the nurse understand the client to be exhibiting? ABGs pH - 7.35 PaO2 - 95% PaCO2 - 49 HCO3 - 30 1. Respiratory acidosis compensated 2. Respiratory acidosis partially compensated 3. Metabolic acidosis compensated 4. Metabolic acidosis partially compensated

1

A client has been admitted with advanced Cirrhosis. The nurse's assessment of the abdominal girth verifies an increase in 5 inches (12.7 cm) and an increase in 6 lbs. (2.72 kg) since yesterday's measurements. The client reports a decreased desire to eat due to gastric reflux and is having steatorrhea. Which interventions would the nurse expect to see in this client's plan of care? 1. Administer pantoprazole 40 mg by mouth every morning. 2. Prepare client for thorocentesis. 3. Infuse Albumin, human 25% 50 mL over 1 hour. 4. Provide a diet of 1500 calories per day. 5. Administer Vitamins A, D, and E in water-soluble form.

1,3 &5

A client was admitted 48 hours ago in septic shock. Treatment included oxygen at 40% per ventimask, IV therapy of Lactated Ringer's (LR) at 150 mL/hr, vancomycin 1 gram IV every 8 hours, and methylprednisolone 40 mg IVP twice a day. Which clinical data indicates that treatment has been successful? 1. pH- 7.35; pCO2- 44; pO2 -92; HCO3- 22 2. Skin cool, mottled 3. Urinary output of 300 mL/8 hr 4. Vital signs: Blood pressure 90/52; HR 110; RR 22 5. WBC 10,500/mm3 (10.5 x 10^9)/L

1,3 &5

A nurse is caring for a client who was admitted with severe dehydration due to excessive vomiting. Which data noted by the nurse validates this diagnosis? 1. Atrial fibrillation 2. Capillary refill 2 seconds 3. Eyes appear sunken 4. Hematocrit 55% 5. Several small furrows on tongue

1,3,4 &5

The nurse is caring for a client admitted to the unit with heart failure. Upon entering the room, the nurse notes that the client is agitated, gasping for air, and attempting to sit up. The client states "I can't get my breath". What actions should the nurse take? 1. Elevate the head of the bed to sitting position 2. Elevate client's legs on two pillows 3. Initiate oxygen at 2 liters per nasal cannula 4. Initiate IV of lactated ringers 5. Administer morphine 2 mg IV

1,3,5

A client is being treated for fluid volume deficit with D5W, oral hydration, and management of viral symptoms. Which client data would indicate to the nurse that further treatment is needed? 1. BP 120/70 lying; 98/68 standing 2. Bounding pulses 3. One day weight gain of 5 kg 4. Urine specific gravity of 1.010 5. Serum sodium 145 mEq (145 mmol/L)

1,2 &3

The Emergency department nurse is caring for a client who has sustained a high-voltage electrical injury. Which intervention should the nurse initiate? 1. Initiate continuous cardiac monitoring. 2. Identify entrance and exit wounds. 3. Give analgesic by mouth as needed. 4. Keep burned limbs below the level of the heart. 5. Cover burned areas with clean sheets.

1,2,3 &5

What should the nurse assess when examining a client who has had a fasciotomy of the forearm? 1. Brachial pulse 2. Capillary refill 3. Color 4. Presence of thrill 5. Skin turgur

2 & 3

A client's arterial blood gas report has arrived at the nurses' station. Based on the results what interventions are required by the nurse? pH - 7.47 PaCO2 - 29 HCO3 -23 PO2 95%. 1. Start oxygen at 2 liters/min 2. Instruct client on taking slow deep breaths 3. Monitor serium sodium level 4. Initiate safety precautions 5. Administer sodium bicarbonate 1 ampule IVP

2 & 4

Based on the results of the arterial blood gases (ABGs), what imbalance does the nurse understand the client to be exhibiting? ABGs pH - 7.36 PaCO2 - 55 HCO3 - 32 O2 - 93% 1. Metabolic acidosis 2. Respiratory acidosis 3. Metabolic alkalosis 4. Respiratory alkalosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

2 & 7

A new nurse asks the charge nurse for assistance in interpreting arterial blood gases (ABGs) for a client. What acid/base imbalance should the charge nurse tell the new nurse these ABGs indicate in the client? ABGs pH - 7.46 PaO2 - 97% PaCO2 - 47 HCO3 - 28 1. Metabolic acidosis 2. Respiratory alkalosis 3. Metabolic alkalosis 4. Respiratory acidosis 5. Uncompensated 6. Partially compensated 7. Fully compensated

3 & 6

Which signs and symptoms would concern the nurse if assessed in a client post radical neck surgery? 1. Decreased deep tendon reflexes 2. Flaccid muscle tone 3. Laryngeal stridor 4. Muscle cramps 5. Negative Trousseau's sign

3,4

The nurse is reviewing morning laboratory results for multiple clients. Which client laboratory results should the nurse immediately report to the Healthcare provider? 1. Client with chronic obstructive pulmonary disease (COPD) and a PCO2 of 50 mm Hg. 2. Diabetic client with fasting blood sugar of 145 mg/dL (8.0 mmol/L). 3. Cardiac client on furosemide with potassium of 3.1mEq/L (3.1 mmol/L). 4. Client with sepsis and total white blood cell count of 16,000 mm3. 5. Client following a thyroidectomy with calcium level of 8.0 mg/dL (2 mmol/L).

3,5

A nurse educator has completed an educational program on interpreting arterial blood gases (ABGs). The educator recognizes that education was successful when a nurse selects which set of ABGs as compensated respiratory alkalosis? 1. pH - 7.46, PaCO2 - 30, HCO3 - 26 2. pH - 7.45, PaCO2 - 35, HCO3 - 25 3. pH - 7.36, PaCO2 - 43, HCO3 - 24 4. pH - 7.43, PaCO2 - 31, HCO3 - 20

4

An elderly, confused client with dehydration is admitted to the medical unit. Which intervention would be appropriate for the RN to delegate to the unlicensed assistive personnel? 1. Perform a physical assessment. 2. Start an IV of NS with KCL 20 mEq at 50 mL/hr. 3. Insert a urinary catheter. 4. Weigh the client.

4

The charge nurse is evaluating a new nurse who is performing a linear wound dressing change on a surgical client. Which action by the new nurse requires intervention by the charge nurse? 1. Hand hygiene is done prior to the dressing change. 2. Dressing tape is removed in the direction of the hair growth. 3. The soiled dressing is discarded in a biomedical waste bag. 4. Clean gloves are donned in order to clean the wound. 5. The wound area farthest from the nurse is cleaned first, then the center of the wound, followed by the area closest to the nurse. 6. New sterile dressing is applied to the wound.

4 &5

An adult client has partial and full thickness burns over the anterior trunk, the anterior and posterior aspect the left leg, the anterior aspect of the right leg, and the peritoneal area. Utilizing the rule of nines, what percentage of the body surface area is burned? Round your answer to the nearest whole number.

46