NR 226 Exam 2 Practice NCLEX

NR 226 Exam 2 Practice NCLEX questions with answers and rationales 2023

• A nurse assesses a patient with hypoparathyroidism. The

nurse notes a positive Chvostek’s sign and recognizes that it indicates with electrolyte imbalance?

• Hyperkalemia
• Hypermagnesemia
• Hypocalcemia
• Hyponatremia

Explanation: Serum calcium levels are maintained through

dietary intake and the parathyroid hormone. When more calcium is needed, parathyroid hormone is released to absorb calcium from bone, stimulate vitamin D activation, inhibit kidney excretion of calcium and stimulate kidney reabsorption of calcium. In hypoparathyroidism, the parathyroid gland does not produce adequate parathyroid hormone to maintain serum calcium levels, causing hypocalcemia.Hypocalcemia is an electrolyte imbalance in which total serum calcium is less than 8.5 mg/dL. Hypocalcemia can cause neuromuscular excitability, as seen in positive Chvostek sign. A positive Chvostek sign occurs when the nurse taps on the facial nerve at the angle of the jaw,

resulting in contraction of the facial muscles.

• A nurse receives a laboratory report for a client indicating

a potassium level of 5.3 mEq/L. When notifying the provider, the nurse should expect which of the following actions?

• Starting an IV infusion of 0.9% sodium chloride
• Consulting with the dietician to increase intake of

potassium

• Initiate continuous cardiac monitoring
• Prepare the client for gastric lavage

Explanation: A potassium level of 5.3 mEq/L indicates

hyperkalemia. Anticipate the initiation of continuous cardiac monitoring due to the client’s risk for dysrhythmias (ventricular fibrillation). Initiate an IV infusion of a fluid containing dextrose to promote the movement of potassium from ECF to ICF. Withhold oral potassium and provide the client with a potassium- restricted diet. Gastric lavage is not indicated for the treatment of hyperkalemia. However, prepare the client for dialysis if hyperkalemia becomes severe.

• A nurse is collecting data from a client who is receiving IV

therapy and reports pain in the arm, chills, and “not feeling well.” The nurse notes warmth, induration, and red streaking on the client’s arm close to the IV insertion site.Which of the following actions should the nurse plan to

take first?

• Obtain a specimen for culture
• Apply a warm compress
• Administer analgesics
• Discontinue the IV infusion

Explanation: The greatest risk to this client is further

injury to the irritated vein. The first action is to stop the infusion and remove the catheter to prevent further harm.Obtaining a specimen for culture to identify pathogens causing infection, however discontinuing the IV infusion is the priority. Applying a warm compress to promote healing and comfort, however discontinuing the IV infusion is the priority. Administer analgesics to promote comfort, however discontinuing the IV infusion is the priority.

• A nurse initiates a blood transfusion at 1100 for an elderly

client who is anemic. The nurse sets the infusion rate to ensure the transfusion is complete by what time?

A. 1200

B. 1300

C. 1500

D. 1600

Explanation: When a provider prescribes a blood

transfusion, the rate of transfusion is usually specified in the