NCLEX Questions-Week 4

The nurse is teaching a client with a urinary stoma about how to change the collection bag and appliance at home. Which of the following client statements indicate an understanding of the procedure?

"The pouch needs to be changed every 5 to 7 days."

A client has been admitted to the hospital with a diagnosis of severe nausea and vomiting. The client has an indwelling intravenous (IV) catheter. The nurse reviews the client's laboratory test results and plans for the administration of which IV fluids that would provide free water, sodium, and chloride to the client? Select all that apply. Tests and Results Sodium 130 mEq/L Chloride 92 mEq/L

-0.45% sodium chloride in water solution -Dextrose 5% in 0.225% sodium chloride solution

The nurse is planning to reinforce dietary teaching about following a diet that is low in potassium to a client receiving a potassium-retaining (sparing) diuretic. The nurse would be sure to include which strategies to avoid foods high in potassium in the diet? Select all that apply.

-Avoid eating lunch meats and bolognas. -Eat salads with cabbage and lettuce, and avoid spinach. -Use eggs as a source for protein.

The nurse is assisting in the care of a client with a new ileostomy on the clinical nursing unit. Which observations indicate to the nurse that the client is at risk for fluid volume deficit? Select all that apply.

-Blood pressure (BP) 104/66 mm Hg, temperature 98.4° F, pulse 106 beats per minute, respirations 20 breaths per minute -Ileostomy output of 650 mL in 4 hours

A client is admitted with a diagnosis of pneumonia and dehydration. The nurse monitors the client and determines that which symptoms correlate with this client's fluid imbalance? Select all that apply.

-Flat neck veins -Weakly palpable peripheral pulses -Heart rate of 104 beats per minute

A client has a prescription to take sodium polystyrene sulfonate for several days. The client also needs to make some dietary changes. Which foods would the client avoid? Select all that apply.

-Mushrooms -Strawberries -Cabbage

The nurse is reviewing the magnesium laboratory result of a client hospitalized with a diagnosis of Crohn's disease. Based on the result, which nursing interventions would the nurse initiate? Select all that apply. Test and Results Magnesium 1.0 mEq/L

-Notify the physician of the laboratory results. -Monitor the client for dysrhythmias.

The nurse is caring for a client with Crohn's disease who has a calcium level of 8 mg/dL. Which patterns would the nurse watch for on the electrocardiogram? Select all that apply. Test and Result Calcium 8 mg/dL

-Prolonged QT interval -Prolonged ST segment

The nurse is caring for a group of clients on a clinical nursing unit. The nurse interprets that which assigned clients are at risk for excess fluid volume? Select all that apply.

-The client with chronic cirrhosis -The client with renal failure

The nurse is calculating a client's 24-hour fluid intake. The client consumed coffee (8 oz), water (8 oz), and orange juice (6 oz) for breakfast; soup (4 oz) and iced tea (8 oz) for lunch; and milk (10 oz), tea (8 oz), and water (8 oz) for dinner. The client also consumed 24 oz of water during the day. How many milliliters of fluid did the client consume in the 24-hour period? Fill in the blank.

2,520 mL

The surgeon asks the nurse to obtain a urinary catheter that will be used for continuous bladder irrigation. Which urinary catheter would the nurse obtain?

A triple-lumen catheter

The nurse is assisting in caring for a client with severe hyponatremia resulting from hypervolemia. The nurse anticipates that which treatment would be prescribed by the physician?

Administer hypertonic normal saline solution intravenously.

The nurse admits a client with a diagnosis of dehydration and a positive history of cancer to the nursing unit. The client is extremely weak and has an irregular heart pulse rhythm. There are absent bowel sounds, and the client's last bowel movement was 4 days earlier. The nurse plans to review serum electrolyte levels because the client is at high risk for which electrolyte imbalance?

Hypercalcemia

The nurse is assigned to care for a group of clients on the clinical nursing unit. The client with which condition is least likely to develop third spacing of fluids?

Hypertension

The nurse is preparing to irrigate a client's sigmoid colostomy. The nurse would plan for which intervention to perform this procedure?

Instilling 500 to 1000 mL of lukewarm tap water through the stoma

The nurse is reading a physician's progress notes in the client's record and reads that the physician has documented "insensible fluid loss of approximately 800 mL daily." The nurse plans to monitor the client, knowing that insensible fluid loss occurs through which type of excretion?

Integumentary output

The nurse is assisting in the care of a client who sustained a crush injury to the left foot. The nurse determines that the client developed third spacing of body fluid based on which observation?

Left foot has 4+ pitting edema.

The nurse is assisting in caring for a client who is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The nurse is monitoring the client for signs of hyperkalemia. Which sign or symptom would be noted in the client if hyperkalemia is present?

Muscle weakness

The staff nurse is observing a new graduate nurse provide indwelling urinary catheter care to an uncircumcised client. Which action by the new graduate nurse would indicate a need for further teaching?

Removes a loose catheter anchor and places a new anchor on the shin

The nurse is inserting an indwelling urinary catheter in a client. As the nurse begins to inflate the balloon, the client starts to complain of pain. Which action would the nurse take?

Stop inflating the balloon, allow the saline solution to drain into the syringe, and advance the catheter farther before reinflating the balloon.

Risedronate, an antihypercalcemic medication, is prescribed for a client. Which information would the nurse reinforce when instructing the client about taking this medication?

Take 2 hours before meals.

The nurse checks a client's skin turgor and documents that the client exhibits normal fluid balance. Which statement correctly describes what the nurse has documented?

The skin when pinched immediately fell back to normal when released.

A client undergoing renal dialysis is prescribed calcitriol to treat hypocalcemia. The nurse reinforces instructions and informs the client that this medication is also known as which nutrient?

Vitamin D