nclex pn fundamentals

nclex pn fundamentals ScienceMedicineNursing andria_montgomery Save Saunders NCLEX~Fluids and electro...50 terms shelbylj06Preview Saunders NCLEX SAFETY 49 terms ebonie_brunson Preview Exam Cram NCLEX-PN PRACTICE Q...103 terms summer3266Preview NCLEX 50 terms joc The intravenous prescription is 1000 mL of 0.9% NaCl (normal saline) to run over 12 hours. The drop factor is 15 gtts/1 mL. The nurse plans to adjust the flow rate to how many gtts/minute? Fill in the blank and record the answer to the nearest whole number.21 The nurse is encouraging a client who is incontinent to participate in recreational therapy. Which nursing intervention should the nurse consider performing first?Change the client's soiled disposable brief.The nursing instructor asks the student to describe isotonic dehydration. The student correctly responds by stating which pathophysiological process?"Water and electrolytes are lost in approximately the same proportion as they exist in the body." A health care provider's prescription reads "cyanocobalamin (vitamin B12) 100 mcg intramuscular." The medication label reads "cyanocobalamin (vitamin B12), 0.5 mg/mL." The nurse administers how many milliliters to the client? Fill in the blank. Record the answer to one decimal place.

0.2 The nurse is assisting to admit a client with a diagnosis of Guillain-Barré syndrome. The nurse knows that if the disease is severe enough, the client will be at risk for which acid-base imbalance?Respiratory acidosis

The nurse is assisting in the care of a group of clients on the nursing unit. The nurse determines that a client with which diagnosis is the one who has the least likely risk for developing third-spacing of body fluid?Ischemic stroke A client is to have an upper gastrointestinal (GI) series. Which nursing action should be done concerning the procedure?Administer a laxative after the procedure because barium was administered.The nurse is preparing to change the neck ties on a tracheostomy tube. Which action should the nurse take?Obtain a second health care team member to assist.A client who has undergone a barium enema is being readied for discharge from the ambulatory care unit. Which statement by the client indicates understanding of the discharge instructions?"I should take a laxative and my stool should return to normal color." A client has been diagnosed with metabolic alkalosis. Which laboratory value(s) is most important for the nurse to monitor for this client?Arterial blood gases (ABGs) A child has been diagnosed with meningococcal meningitis. Which precautionary technique is appropriate to prevent transmission of the disease?Isolation precautions for at least 24 hours after the initiation of antibiotics A health care provider has prescribed phytonadione 2.5 mg intramuscularly. The nurse reads the label on the medication vial and administers how many mL to the client? Refer to the figure and fill in the blank. Record your answer to two decimal places.

0.25 A lethargic, pale child is brought to the health care provider's office with symptoms of periorbital edema and reduced quantity of urine output.The urine is cloudy and smoky in color. The nurse asks the mother if the child has had any recent infections, to which the mother responds that the child had a very sore throat a few weeks ago. The health care provider suspects that the child might have acute poststreptococcal glomerulonephritis. Which laboratory test would rule out a past streptococcal infection in the child?Antistreptolysin titer The nurse is assigned to assist in caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are as follows: blood pressure (BP) 102/62 mm Hg, pulse 91 beats per minute, respirations 16 breaths per minute. Preoperative vital signs were BP 124/78 mm Hg, pulse 74 beats per minute, respirations 20 breaths per minute. Which action should the nurse plan to take first?Recheck the vital signs in 15 minutes.The nurse is told that an assigned client is suspected of having methicillin-resistant Staphylococcus aureus (MRSA). Which precautions should the nurse institute during the care of the client?Wear a gown and gloves.

A client with a history of seizure disorder is taking phenytoin (Dilantin). The nurse reviews the laboratory results of the phenytoin level and determines that the client has been noncompliant with medication therapy if which laboratory result is noted?

• mcg/mL

The nurse is observing a nursing student preparing to obtain a throat culture on a client suspected of having a beta-hemolytic Streptococcus infection. Which action indicates the need for further teaching regarding collecting this specimen? Select all that apply.The student asks the client to tilt the head forward and to open the mouth.The student places the collection swab initially at the back of the client's tongue.Which nursing action would avoid pressure on the popliteal nerve when applying the safety strap across the client's legs on the operating table?Apply the safety strap 2 inches above the knees.The nurse is caring for an elderly Hispanic client who is a migrant farm worker and has been admitted for asthma. The nurse is unfamiliar with the cultural practices and beliefs of the client's home land. Which questions are appropriate for the nurse to ask when caring for this client? Select all that apply.What do you believe is causing your illness?Are there any remedies you have used in the past?Who do you usually see for help when you are sick The nurse is assigned to assist in caring for a client who has had an autograft placed on the anterior lower extremity. Which activity should the nurse include in the plan of care?Elevate and immobilize the surgical extremity.The nurse hangs a 1000-mL intravenous (IV) bag of 5�xtrose in water (D5W) at 0700. The IV is to infuse at 100 mL/hr, and the nurse places a time tape on the IV bag. At noon the nurse should expect that the infusion line on the IV bag would be at which point? Refer to figure.2 The nurse is reading a client's urinalysis report. The nurse interprets which item found on the report to be considered abnormal?Positive protein The nurse is assigned to care for a client on contact precautions. On review of the client's record, the nurse notes that the client has a hospital- acquired infection caused by methicillin-resistant Staphylococcus aureus (MRSA). The client has an abdominal wound that requires irrigation and has a tracheostomy attached to a mechanical ventilator and requires frequent suctioning. The nurse gathers supplies before entering the client's room and obtains which necessary protective items?Gloves, mask, gown, and goggles

The skin surrounding a postoperative client's abdominal wound is becoming irritated in the area where the dressing tape is being reapplied with each dressing change. Which is the appropriate nursing action?Apply Montgomery ties.The nurse monitors the postoperative client frequently, knowing that accumulated secretions can lead to which problem?Pneumonia The medication prescribed is hydromorphone hydrochloride (Dilaudid), 3 mg intramuscularly, every 4 hours as needed. The medication label reads hydromorphone hydrochloride (Dilaudid), 4 mg/1 mL. The nurse should prepare to administer how many mL to the client? Fill in the blank.

0.75 The nurse is reinforcing instructions to a client regarding how to decrease the intake of phosphorus in the diet. The nurse should tell the client that which food item contains the least amount of phosphorus?Oranges Fentanyl 75 mcg intravenous push (IVP) has been prescribed by the health care provider. The medication ampule reads fentanyl 50 mcg/mL. The nurse should prepare how many milliliters to administer the correct dose? Fill in the blank and record your answer using one decimal place.

1.5 A client with a seizure disorder is taking phenytoin (Dilantin). A sample for a serum phenytoin level is drawn, and the nurse determines that the next dose of the medication may be administered if which laboratory result is noted?17 mcg/mL The nurse is reading the health care provider's (HCP's) progress notes in the client's record and sees that the HCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss?Client with a fast respiratory rate 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 action to properly care for this client for the remainder of the shift?Test the urine for occult blood.The nurse is caring for a client who has a wound infection. Contact precautions are being followed. Which are correct actions by the nurse when using personal protective equipment (PPE)? Select all that apply.Perform hand hygiene after removal of PPE.Perform hand hygiene before donning any PPE.When removing PPE, always remove gloves first Protective eyewear and face shield are indicated if there is risk of splatter.