NR 226 Exam 2 Practice NCLEX questions with answers and rationales

NR 226 Exam 2 Practice NCLEX questions with answers and rationales

• 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? This study source was downloaded by 100000829085622 from CourseHero.com on 07-17-2021 20:31:59 GMT -05:00 https://www.coursehero.com/file/96544505/NR-226-Exam-2-Practice-NCLEX-questions-with-answers-and-rationalespdf/ This study resource was shared via CourseHero.com

• 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 prescription. A nurse should ensure the transfusion is complete by 4 hours of initiation. An elderly client who is anemic has no need for a rapid transfusion and could be compromised if transfused too rapidly. Blood transfusions should be complete by 4 hours of initiation due to the increased risk of sepsis from bacterial contamination after the blood is exposed to room temperatures for that long.

• A nurse administers PRBCs to a client. Fifteen minutes after beginning the transfusion, the client

reports pain in the back, burning at the IV site, and chills. Which actions does the nurse take?(Select all that apply)

• Decrease the blood transfusion flow rate
• Finish the transfusion and then notify the blood bank
• Notify the health care provider of the client’s status
• Save the blood bag and tubing and call the blood bank
• Stop the blood transfusion immediately

This study source was downloaded by 100000829085622 from CourseHero.com on 07-17-2021 20:31:59 GMT -05:00 https://www.coursehero.com/file/96544505/NR-226-Exam-2-Practice-NCLEX-questions-with-answers-and-rationalespdf/ This study resource was shared via CourseHero.com

Explanation: Acute hemolytic transfusion reactions are commonly caused by an ABO incompatibility and occur during the transfusion or within 24 hours. The client may report burning at the IV site, chills, and pain in the back and flank. Fever may be noted. Incompatible RBCs with antigens from the wrong blood group attacked and destroyed by antibodies in the client’s plasma, leading to widespread hemolysis. These antibodies activate complement, and tissue factor is released by RBC debris, which triggers the clotting cascade. Disseminated intravascular coagulation results, causing shock, acute renal failure, and even death. If a hemolytic reaction occurs, the nurse should immediately stop the transfusion first and infuse normal saline with a new IV line. The nurse should then notify the health care provider. Infusing normal saline will initiate diuresis and help avoid hypotension and vascular collapse. Save the blood container, tubing, attached labels, and transfusion record for return to the blood bank.

• A client with type 1 diabetes mellitus arrives in the emergency care unit after being found

unconscious. The nurse notes the client’s breath is fruity and expects to see which set of arterial blood gas results?

• pH: 7.28, PaCO2: 40, HCO3: 16
• pH: 7.31, PaCO2: 50, HCO3: 29
• pH: 7.38, PaCO2: 45, HCO3: 26
• pH: 7.49, PaCO2: 32, HCO3: 21

Explanation: Diabetic Ketoacidosis (DKA) leads to metabolic acidosis due to the breakdown of fatty acids for fuel in the absence of available glucose. As a result of fatty acid breakdown, ketoacids, a very strong group of acids that create large amounts of hydrogen ions, are produced and lower blood pH. Metabolic acidosis may also be caused by other conditions that increase acids, such as starvation or from a decrease in base. Answer B indicates partially compensated respiratory acidosis. Answer C indicates lab values within the normal range. Answer D indicates respiratory alkalosis.

• The nurse cares for an older adult client admitted following surgery. The nurse discusses the

client’s pain management with a student nurse. Which statement by the student indicates further education is needed?

• “Analgesics have a longer duration in older adults.”
• “Older adults often underreport their pain.”
• “Pain can be present even if a client is sleeping.”
• “Pain is a natural outcome of the aging process.”

Explanation: Pain is an individual experience and is the most common reason people seek health care. Nurses need to recognize the subjective nature of pain and accept the client’s description of pain. Cultural aspects include age, gender, education, diagnosis, and client This study source was downloaded by 100000829085622 from CourseHero.com on 07-17-2021 20:31:59 GMT -05:00 https://www.coursehero.com/file/96544505/NR-226-Exam-2-Practice-NCLEX-questions-with-answers-and-rationalespdf/ This study resource was shared via CourseHero.com

knowledge can impact a nurse’s perception of the client’s pain. Biases and misconceptions about pain impact a client’s comfort and care. Older adults are at a greater risk than younger adults for painful conditions. However, pain is not an inevitable result of aging. Due to declined liver and renal function, older adults often have reduced metabolism and excretion of drugs. This results in a greater peak effect and longer duration of analgesics.Older adults underreport pain for many reasons, including the following: believing that pain is expected with age, protecting loved ones, fearing loss of independence, and not wanting to bother caregivers. Older adults may also believe caregivers know they have pain and feel they do not need to report it. Older adult clients may believe showing pain is unacceptable and learn ways to cope with the pain, such as sleeping or other distraction techniques.

• The school nurse is teaching health-promoting behaviors that improve sleep to a group of high-

school students. Which points should be included in the education? (Select all that apply)

• Go to bed at the same time each night.
• Study in your bedroom to have a quiet place.
• Avoid drinking coffee or soda before bedtime.
• Turn off your cell phone at bedtime.

Explanation: Going to bed at the same time each night, avoid drinking coffee and soda before bedtime, and turning off electronic devices are effective sleep hygiene practices for adolescents. Use of electronic devices is a main cause of sleep disruption in adolescents.Good sleep-hygiene practices state that the bedroom should only be used for sleeping.Work and study should not be done in the bedroom.

• An older adult client comes to the primary care clinic and mentions trouble with constipation.

The nurse includes which instructions to the client for preventing constipation? (Select all that apply)

• Exercise regularly.
• Include fiber in the diet.
• Increase fluid intake.
• Take a daily laxative.

Explanation: Constipation can be a common problem for older adults. It can be a source of discomfort, making daily activities more difficult. It can also contribute to the development of anxiety, depression, and decreased social activities. Furthermore, it can lead to bowel obstruction, which can be life-threatening. Older adults should perform regular exercise as long as they are medically able to do so. Exercise increases bowel motility and helps to prevent constipation. Fiber should be included in the diet to help prevent constipation. Older adults should consume 35 to 50 grams of fiber daily. Fluids promote regular bowel movements by increasing the water drawn into the colon and making stools softer. Older adult clients should drink at least 2 liters of fluid a day unless medically contraindicated. This study source was downloaded by 100000829085622 from CourseHero.com on 07-17-2021 20:31:59 GMT -05:00 https://www.coursehero.com/file/96544505/NR-226-Exam-2-Practice-NCLEX-questions-with-answers-and-rationalespdf/ This study resource was shared via CourseHero.com