Archer NCLEX Study Bank Questions

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NCLEX EXAM PREVIEW

110 terms kandykat1012Preview Archer NCLEX questions from lectur...46 terms Annette_Picone Preview NCLEX 133 term Fam The nurse is calculating the 12-hour intake for a client.The client received 0.45% saline at 85 mL/hr via continuous infusion One eight-ounce cup of ice chips One eight-ounce cup of coffee One eight-ounce cup of ice cream Three eight-ounce cups of water One eight-ounce cup of pureed vegetables The nurse should calculate the client's total liquid intake as how many mL?

Explanation:

The client received 0.45% saline at 85 mL/hr x 12 hours → 1020 mL One eight-ounce cup of ice chips → 120 mL When determining the total mL for a cup of ice, the nurse should divide the volume by 1/2 since the ice melts One eight-ounce cup of coffee → 240 mL One eight-ounce cup of ice cream → 240 mL Three eight-ounce cups of water → 720 mL One eight-ounce cup of pureed vegetables → This is excluded from the intake calculation as pureed food(s) are not a liquid at room temperature Total → 2340 mL

The nurse has several tasks that need to be completed.Which of the following client assignments would be appropriate to delegate to the unlicensed assistive personnel?

• A 65-year-old male requiring sterile dressing changes.
• A 26-year-old female requiring a one-person assist in

ambulating to the restroom.

• An 80-year-old male who is receiving enteral feedings

continuously through an NG tube.

• A 23-year-old client requiring frequent urinary

specimen collections from their indwelling urinary catheter.Choice B is correct. A 26-year-old female requiring one person to assist in ambulating to the restroom would be an appropriate assignment for unlicensed assistive personnel (UAP). The UAP is skilled in assisting clients with ambulation, which is within their scope of practice.Choice A is incorrect. A 65-year-old male requiring sterile dressing changes would not be an appropriate assignment for unlicensed assistive personnel.Simple dressing changes are not performed by unauthorized personnel. The UAP does not have the requisite knowledge and experience for this task.Choice C is incorrect. An 80-year-old male who is continuously receiving enteral feedings through an NG tube would not be an appropriate assignment for unlicensed assistive personnel. Administering tube feedings is not performed by unlicensed personnel.Choice D is incorrect. UAPs may assist with clean catches, but collecting urine specimens from the indwelling urinary catheter is not within their scope. This requires an LPN/VN or RN, as the specimen is not obtained from the collection bag. It is obtained by clamping the tubing and with a sterile syringe.The nurse cares for a 12-year-old client one hour post- operative following transsphenoidal hypophysectomy.After reviewing the assessment findings, the nurse should take which action? Select all that apply. See the exhibit.notify the health care provider of the urine output.request an order for intravenous (IV) fluids document the findings administer supplemental oxygen continue to monitor neurological status Choices A, B, C, and E are correct.A is correct. This is an excessive amount of urine output for 1 hour and is concerning for diabetes insipidus, given the procedure the client recently underwent. Any urine output greater than 300 mL is alarming, and the healthcare provider should be notified immediately. Diabetes insipidus is a severe complication from neurosurgery that occurs around the pituitary. This amount of urinary output can lead to shock if not treated promptly.B is correct. Given the assessment, requesting an order for IV fluids is an appropriate nursing action. The nurse should be concerned about the possibility of DI considering the excessive urine output, and no fluid replacement is currently ordered for this client. This is concerning for shock, and IVF should be initiated to rehydrate and adequately replace losses from the urinary output.C is correct. These findings should be accurately documented to ensure proper follow-up and orders for this client.E is correct. The client's neurological status should be monitored, as mental status and behavior changes can indicate electrolyte imbalances, such as hyponatremia.Choice D is incorrect. No oxygen therapy is indicated for this client at this time.The oxygen saturation is adequate on room air.The nurse is assessing a client with diabetic ketoacidosis (DKA). Which of the following would be an expected finding?Select all that apply.Thready pulse Jugular venous distention (JVD) Coarse tremors Tachycardia Orthostatic hypotension Choices A, D, and E are correct. A client presenting with DKA will have signs and symptoms of dehydration that range from mild to severe. Tachycardia is a common finding in DKA because of the fluid volume deficit. This, in turn, causes a client to have a thready pulse. Orthostatic hypotension is also a common finding because of dehydration.Choices B and C are incorrect. JVD is a finding associated with fluid volume overload. A client with DKA will not have this sign because DKA is associated with dehydration. Coarse tremors would be a neurological finding that would be concerning for neurodegenerative diseases such as Parkinson's. Coarse tremors are not an expected finding with DKA.

The nurse is reviewing laboratory data for assigned clients. Which laboratory result requires immediate follow-up with the primary healthcare provider (PHCP)?

• Elevated amylase result in a client diagnosed with

acute pancreatitis

• Elevated white blood cell (WBC) count in a client with

an infected leg wound.

• Urinalysis positive for leukocytes and nitrites for a

client receiving chemotherapy

• Serum glucose of 235 mg/dL (13.05 mmol/L) [70-110

mg/dL, 4.0-11.0 mmol/L] in a client with diabetes mellitus (type one) Choice C is correct. Chemotherapy agents increase clients' risk of infection due to immune suppression, specifically by decreasing neutrophils. Neutropenia, a reduction in the blood neutrophil count, is common in chemotherapy clients. The client's risk of bacterial and fungal infections increases with worsening neutropenia. Furthermore, if a bacterial or fungal infection occurs, the infection's likelihood of spreading to other parts of the body increases. Early antibiotic intervention may prevent sepsis. In a urinalysis, the presence of leukocytes and nitrites is indicative of a urinary tract infection. This result should alert the nurse regarding a potential urinary tract infection in this immunocompromised client, warranting the nurse to notify the PHCP of the result so a complete blood count (CBC) can be obtained and antibiotic therapy may be initiated immediately.Choice A is incorrect. An elevated amylase result in a client diagnosed with acute pancreatitis is an anticipated finding and would not warrant reporting the result to the PHCP.Choice B is incorrect. In a client diagnosed with an infected leg wound, an elevated white blood cell count (leukocytosis) is an anticipated finding.Leukocytosis usually occurs in response to infection, trauma, or inflammation.Since this client is known to be septic, the leukocytosis is an expected finding and, therefore, does not warrant the nurse immediately reporting this lab result to the PHCP.Choice D is incorrect. The client's serum glucose level of 235 mg/dL (13.05 mmol/L) is above the normal range of 70-110 mg/dL (4.0-11.0 mmol/). However, this is a relatively common finding in clients with type I diabetes mellitus and does not necessitate immediate reporting to the PHCP.The nurse is caring for a client receiving a continuous infusion of norepinephrine. The nurse should plan to monitor which of the following for the client?Select all that apply.Blood pressure Intracranial pressure Intravenous site Urine output Blood glucose Choices A, C, D, and E are correct. An infusion of norepinephrine is indicated if the client is in shock. This medication helps restore vascular tone and is useful in treating life-threatening hypotension. This medication is a vesicant, and the preferred delivery is through a central line. If this is not possible, a large-bore intravenous catheter should be utilized. The patency of this catheter should be assessed frequently to prevent damaging extravasation. Blood pressure must be monitored continuously while this medication is administered to assess the desired response of increased vascular tone. This medication causes vasoconstriction, decreasing renal blood flow and decreasing urine output. Norepinephrine causes an increase in blood glucose because of its ability to cause the liver to discharge more glucose by breaking down glycogen.Choice B is incorrect. Norepinephrine is a medication used in the management of shock. The nurse must monitor the client's blood pressure, intravenous site, urine output, and blood glucose. One of the monitoring parameters not indicated is intracranial pressure (ICP) - this would be more applicable if the medication was mannitol.

The nurse is preparing medications for the shift. Which of the following clients should the nurse prioritize for immediate medication administration?

• Digoxin to a client with atrial fibrillation
• Furosemide to a client with congestive heart failure
• Magnesium sulfate to a client with Torsades de pointes
• Labetalol to a client with a blood pressure of 160/100

mmHg Choice C is correct. Torsades de pointes is an emergency because it is life- threatening and can progress to ventricular fibrillation and sudden cardiac death if not promptly treated. The nurse should immediately administer the prescribed magnesium sulfate to the client to prevent Torsades from degenerating into ventricular fibrillation.Choices B, A, and D are incorrect. All these medications are necessary for these clients and must be administered. However, the client with a more life-threatening condition (Torsades de pointes) should be prioritized.Furosemide is a loop diuretic used to treat congestive heart failure and edema.Digoxin is used to treat atrial fibrillation with the goal of controlling the heart rate and restoring sinus rhythm. However, some recent studies have shown increased mortality with chronic use of digoxin in atrial fibrillation.Labetalol is a beta-adrenergic and a selective alpha-1 adrenergic blocker.Therefore, it is widely used to treat arterial hypertension (from chronic to hypertensive crises). The client's blood pressure is high, but they are not exhibiting signs of target organ dysfunction (stroke, myocardial infarction, or heart failure) to suggest a hypertensive emergency. The client with Torsades de pointes should be attended to before the client with stable hypertension.The nurse is developing a plan of care for a client with a wet-suction chest tube prescribed wall suction. Which interventions would be appropriate to include?Select all that apply.Apply clamps to the tubing to secure it to the bed.Strip the tubing at least once every eight hours.Report any bubbling in the suction control chamber.Ambulate the client with the device below the insertion site.Palpate around the insertion site for any crackles or popping.Choices D and E are correct. Ambulation with a chest tube is not contraindicated.If the nurse has an order from the primary healthcare provider (PHCP) and it is safe for the client to ambulate, the nurse should ambulate the client with the device distal to the insertion site. Palpating around the insertion site should be done and any crackles or popping should be reported to the PHCP because that indicates an air leak.Choices A, B, and C are incorrect. The tubing should not be clamped to the bed as this would cause an obstruction. It would be appropriate to keep extra tubing loose on the bed. Stripping the tubing would be inappropriate because it would increase the intrathoracic pressure, counterproductive to chest tube therapy.Continuous bubbling in the suction control chamber is normal because wall suction is prescribed for this client.The nurse is working at a women's health clinic. A client comes in suspected of having trichomoniasis. Upon physical examination of the perineal region, the nurse should expect which type of sign?

• White, "cheesy" discharge
• Malodorous, thin, yellow discharge
• Grayish-white, malodorous discharge
• No vaginal discharge

Choice B is correct. Trichomoniasis clients would yield a malodorous, thin, yellow discharge. Trichomoniasis is caused by a protozoon, Trichomonas vaginalis.Choice A is incorrect. A white, "cheesy" discharge is indicative of moniliasis or candidiasis, which is caused by Candida albicans.Choice C is incorrect. Grayish-white, malodorous discharges would indicate bacterial vaginosis.Choice D is incorrect. Clients with trichomoniasis yield a malodorous, thin, yellow discharge.