NCLEX-PN FUNDAMENTALS of CARE

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?

1.030 Rationale:The normal range for urine specific gravity, the comparison of urine concentration to water is from 1.016 to 1.022. Elevations may occur with SIADH because the kidneys are stimulated to reabsorb water, thus causing a higher concentration of the urine. The client retains water in the circulating blood volume leading to hyponatremia and low sodium levels, which cause decreased mental alertness and functioning. Specific gravities of 1.016, 1.018, and 1.020 are all within the normal range.

The nurse is caring for a client with kidney failure. The laboratory results reveal a magnesium level of 3.6 mEq/L (1.8 mmol/L). Which sign should the nurse expect to note in the client, based on this magnesium level?

Loss of deep tendon reflexes

A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should plan to place the client in which position?

Supine, with the residual limb supported with pillows

Intravenous (IV) lactated Ringer's (LR) solution is prescribed for a postoperative abdominal surgery client. A nursing student is caring for the client, and the nursing instructor asks the student about why this IV solution is prescribed. Which student response is correct?

"LR is isotonic to plasma and contains electrolytes"

The nurse reinforces instructions to a client who is to return to the primary health care provider's office in 1 week for a patch test to identify the allergen causing the dermatitis. The nurse provides which instruction to the client?

"Discontinue the prescribed antihistamine 2 days before the test."

Which statement by the client should cause the nurse to suspect that the thyroid test results drawn on the client this morning may be inaccurate?

"I had a radionuclide test done 3 days ago."

A primary health care provider has prescribed prochlorperazine 4 mg intramuscularly for a client who is vomiting. The label on the medication vial indicates prochlorperazine 5mg per 1 mL. The nurse administers how many milliliters (mL) to the client? Fill in the blank. Record the answer to one decimal place.

0.8 mL

A client who had knee surgery 4 days ago reports to the home health nurse that he has not had a bowel movement since before the surgery. Which questions would assist the nurse in the collection of data regarding the client's problem? Select all that apply.

1 "What have you been eating and drinking since the surgery?" 2 "Have you been experiencing any urge to move your bowels?" 3 "What kind and how often have you been taking medications for pain?"

The nurse reviews the client's laboratory results. Which abnormal findings should the nurse report? Select all that apply.

1 Calcium 8.2 mg/dL 2 Potassium 6 mEq/L 3 Magnesium 2.9 mg/dL 4 Phosphorus 5.2 mg/dL

A caregiver of a client with an advanced case of acquired immune deficiency syndrome (AIDS) asks the nurse to review instructions in order to take care of the client. Which instructions would be appropriate for the nurse to reinforce? Select all that apply.

1 Wash soiled clothes in hot water. 2 Use gloves when handling body fluids. 3 Soak cleaning rags, sponges and mops in a 1:10 bleach solution for 5 minutes.

The primary health care provider prescribes 1000 mL of 0.45% NaCl to run over 8 hours. The drop (gtt) factor is 15 gtt/mL. The nurse plans to adjust the flow rate to how many gtt/min? Fill in the blank. Round your answer to the nearest whole number.

31 gtt/min

The nurse is caring for a client with respiratory insufficiency. The arterial blood gas (ABG) results indicate a pH of 7.50 and a Pco2 of 30 mm Hg (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?

A potassium level of 3.0 mEq/L (3.0 mmol/L) Rationale: Signs/symptoms of respiratory alkalosis include tachypnea, change in mental status, dizziness, pallor around the mouth, spasms of the muscles of the hands, and hypokalemia. The remaining options identify normal laboratory results.

The nurse is providing directions to a client about how to test a stool for occult blood. The nurse cautions that which could cause a false-negative result?

Ascorbic Acid Rationale: Ascorbic acid can interfere with results of occult blood testing, yielding false-negative results. Colchicine and iodine can cause false-positive results. Acetylsalicylic acid would either have no effect or cause a positive result by inducing bleeding from the gastrointestinal tract.

The nurse is caring for an African-American client admitted for a planned surgery. The nurse enters the room and after a greeting and introduction to the client describes the routine for preparing for surgery. The client looks away from the nurse. Which nursing action is appropriate?

Continue with the explanation.

The nurse is reinforcing discharge instructions to a Chinese client regarding prescribed dietary modifications. During the teaching session, the client continually turns away from the nurse. Which nursing action is most appropriate?

Continue with the instructions, verifying client understanding.

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 (3.0 mmol/L). Based on this laboratory value, the nurse should take which action?

Inform the registered nurse of the laboratory value.

The nurse teaches the family of an infant with spina bifida that the infant should not be given which baby foods that may trigger a latex-type food allergy? Select all that apply.

Kiwi Banana Avocado

In preparing to care for a hospitalized child with a diagnosis of measles (rubeola), which supplies should the nurse bring to the child's room to prevent the transmission of the virus?

Mask and gloves Rationale:Rubeola is transmitted via airborne particles or direct contact with infectious droplets. Respiratory isolation is required, and a mask should be worn by those in contact with the child. Gloves should be worn to prevent transmission via direct contact. Gowns and goggles are not specifically indicated for care of the child with rubeola. Any articles that are contaminated should be bagged and labeled.

The nurse reviews the arterial blood gas results of a client and notes that the results indicate a pH of 7.30, Pco2 of 52 mm Hg, and HCO3- of 22 mEq/L. Which interpretation should the nurse correctly make about these results?

Respiratory acidosis

The nurse reinforces instructions to the parents of a newborn infant regarding car travel and safety seats. Which information related to the safety of the infant is correct?

Restrain in a car seat in the back seat in a semi-reclined, rear-facing position.

The nurse is assisting in monitoring a client who may be started on parenteral nutrition (PN). The nurse reviews the client's laboratory results and determines that the client is at risk of severe malnutrition if the report indicates which critical level?

Serum albumin 2.8 g/dL

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?

The client with a ileostomy

The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L (130 mmol/L). The nurse expects that this sodium level would be noted in a client with which condition?

The client with the syndrome of inappropriate secretion of antidiuretic hormone

A bone marrow aspiration is scheduled for a client suspected of having leukemia. What intervention does the nurse anticipate will be done to protect the aspiration site and client from becoming infected?

The site will be cleansed thoroughly with an antiseptic and allowed to air dry before the procedure.

A client with ascites is scheduled for a paracentesis. The nurse is assisting the primary health care provider (PHCP) with performing the procedure. Which position should the nurse assist the client into for this procedure?

Upright Rationale:An upright position allows the intestine to float posteriorly and helps prevent intestinal laceration during catheter insertion. Options 1, 3, and 4 are incorrect positions.

The nurse is caring for an older Appalachian client recovering from open heart surgery. In order to provide culturally appropriate care, the nurse should be aware that which aspects of reporting pain may be impacted by the Appalachian culture? Select all that apply.

1 Appalachian clients may want to appear to be stoic. 2 Appalachian clients may be afraid of addiction tendencies. 3 Appalachian clients may not want to appear to be complainers. Rationale:In the Appalachian culture, clients often appear stoic and do not want to complain. Clients may not want to appear to be a complainer or a bother to someone, so often they do not report their pain. Addiction tendencies may be a concern to clients from many different backgrounds. It is a common myth that all Appalachian clients are illiterate. The nurse must not assume that all Appalachian clients are illiterate.

Which laboratory results indicate a therapeutic drug level? Refer to chart. Select all that apply.

1 Carbamazepine 10 mcg/mL 2 Gentamicin 8 mcg/mL 3 Theophylline 10 mcg/mL

The nurse is caring for a client who is receiving an intermittent feeding via a nasogastric (NG) tube. Before feeding the client via the NG tube, the nurse should take which actions? Select all that apply.

1 Check the placement of the tube. 2 Aspirate the contents from the nasogastric tube. 3 Observe the characteristics and pH of the aspirate from the nasogastric tube.

A client with a history of seizure disorder is having a routine serum phenytoin level drawn. The nurse who receives a telephone report of the results notes that the client's blood level of the medication is within the normal range if which value is reported?

15 mcg/mL

A primary health care provider's prescription reads potassium chloride 20 mEq in 1000 mL 0.9% NaCl and infuse at 100 mL/hr. The nurse assisting in caring for the client determines that the client will receive how many milliequivalents (mEq) of potassium every hour? Fill in the blank.

2 mEq

A primary health care provider prescribes digoxin (0.5 mg orally daily for a client with heart failure. The medication label states, 0.25 mg per tablet. How many tablet(s) will the nurse administer to the client? Fill in the blank.

2 tablets

The nurse is preparing to administer an intermittent tube feeding to a client. The nurse aspirates 90 mL of residual from the tube. What should the nurse do? Select all that apply.

Document the amount of residual. Reinstill the residual and administer the feeding.

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 Rationale:The loss of gastric fluid via nasogastric suction or vomiting causes a metabolic condition. This also results in an alkalotic condition as a result of the loss of hydrochloric acid through gastrointestinal fluid losses. Also, the options denoting a respiratory problem—respiratory acidosis and alkalosis—can be easily eliminated.

The nurse is providing eye care to an unconscious client. Which interventions are included in the procedure? Select all that apply.

1 Cleanse each eye moving from the inner canthus to the outer canthus. 2 Use a clean wet cotton ball or different area of a clean wash cloth for each eye.

The nurse is preparing a client for the administration of a tuberculin skin test. The nurse determines that which body areas are appropriate for intradermal injections? Select all that apply.

1 Inner aspect of the forearm 2 Dorsal aspect of the upper arm 3 Away from heavy pigmentation

The nurse is caring for a client whose magnesium level is 3 mEq/L (1.5 mmol/L) and the client is being treated for the magnesium imbalance. The nurse interprets that the electrolyte imbalance is resolving if which signs or symptoms are no longer present? Select all that apply.

1 hypotension 2 loss of deep tension reflexes

The nurse is obtaining the report for a group of assigned clients. The nurse plans to monitor the serum potassium levels in which clients at risk for hyperkalemia? Select all that apply.

1 A client with a new burn injury 2 A client diagnosed with acute kidney injury (AKI)

The nurse needs to increase the calcium in the diet of a client who is lactose intolerant. Which food items should the nurse encourage? Select all that apply.

1 Tofu 2 Broccoli 3 Sardines 4 Mustard greens

A client with new onset migraine headaches is being seen in the clinic. The client has a history of hypotension and diabetes mellitus. The nurse understands the client is at risk for cardiac side effects if the primary health care provider prescribes which medications? Select all that apply.

1 Verapamil 2 Propranolol 3Sumatriptan

Arterial blood gases (ABGs) are obtained on a client with pneumonia. The ABG results are pH, 7.50; Pco2, 30 mm Hg; HCO3-, 20 mEq/L; and Po2, 75 mm Hg. The nurse interprets these results and determines that which acid-base condition exists?

Respiratory alkalosis Rationale:Normal pH is 7.35 to 7.45. Normal Pco2 is 35 to 45 mm Hg. Remember that when a respiratory condition exists, an opposite effect will be found between the pH and the Pco2. In respiratory alkalosis, the pH will be elevated and the Pco2 level decreased.

The medication prescribed is levodopa 1 g orally, daily. The medication label states levodopa, 500-mg tablets. The nurse prepares to administer how many tablets at the evening dose? Fill in the blank.

2 tablets

The medication prescribed is digoxin 0.25 mg orally, daily. The medication label reads digoxin 0.125 mg/tablet. The nurse should prepare how many tablet(s) to administer the dose? Fill in the blank.

2 tablets

A client with a diagnosis of tonic-clonic seizures is being admitted to the hospital, and the nurse needs to institute seizure precautions. During a seizure, which items are inappropriate to use and could cause harm to the client? Select all that apply.

1 Restraints 2 Padded tongue blade

The nurse is caring for a client recovering from hepatitis. The nurse recognizes the need to report which laboratory test result to the primary health care provider?

Alanine aminotransferase (ALT) that is significantly elevated Rationale: As tissues in the body are injured, enzymes present in the cells are released and can be monitored through blood tests. It is important to recognize which enzymes are found in which tissues. ALT is found predominantly in the liver, and an elevated level would indicate significant liver damage. The WBC count may be slightly elevated with the hepatitis. Antigens and delta antigen HBsAg, are agents that trigger cell damage; antigens do not result from the damage.

An outbreak of illness has occurred in a community and is suspected to be related to food ingestion. A community health nurse places priority on which intervention?

Determining what common food item was ingested by those affected

A licensed practical nurse (LPN) is providing follow-up teaching after a client underwent an upper gastrointestinal (GI) series with diatrizoate used for contrast. The nurse instructs the client that which may occur from the diatrizoate?

Diarrhea

The nurse monitors the 3-day postoperative client who underwent abdominal surgery. Vital signs are:temperature: 37.9° C (100.2° F), pulse 104 beats per minute, respirations 22 breaths per minute, blood pressure 128/74 mm Hg. Oxygen saturation is 93% on room air. The client feels tired and has a productive cough. Fine crackles are audible in the bases of the lungs posteriorly. The nurse considers the client has developed which postoperative problem?

Pneumonia Rationale: Hypoxia is inadequate concentration of oxygen in the blood and usually occurs as an acute process, such as respiratory depression as a result of anesthesia or analgesia, or the pulmonary oxygen saturation is relatively below normal, less than 92%. Atelectasis occurs 1 to 2 days postoperatively, and auscultation reveals diminished breath sound and/or crackles that clear with coughing. Fluid overload is excessive blood volume with too much fluid in the circulation. It causes coarse crackles and severe dyspnea.

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

1 Instruct the client not to swallow water with oral hygiene on the morning of surgery. 2 Document that any medications the client was instructed to take before surgery are given. Rationale: The nurse cannot just verify the preoperative testing was done. The nurse needs to review the results of the preoperative laboratory studies and notify the primary health care provider of any abnormal results. Some increase in both blood pressure and pulse is common because of client anxiety regarding surgery. The client usually has a restriction of food and fluids for 8 hours before surgery instead of 24 hours.

A licensed practical nurse (LPN) is assisting in the care of a client receiving a continuous intravenous (IV) infusion of heparin sodium for deep vein thrombosis (DVT). The LPN notes that the result of a newly drawn activated partial thromboplastin time (aPTT) level is 90 seconds. The client's baseline before the initiation of therapy was 30 seconds. The LPN should take which action?

Notify the RN about the value immediately. Rationale: The normal aPTT varies between 20 and 36 seconds, depending on the type of activator used in testing. When a client receives intravenous heparin, the range of the aPTT is ordered by the primary health care provider but is greater than the normal range. Heparin treatment for DVT often involves a protocol to follow determined by the results of aPTT. If the aPTT is within the desired level, the rate is maintained and an aPTT is not ordered again until the next morning. The LPN should report the findings immediately to the RN, who will take further action to follow up on the elevated value. Checking for pain from the DVT, checking for additional heparin, and delaying reporting the aPTT are not appropriate actions.