Fundamentals Of Nursing NCLEX Quiz 45

1. For a client who is taking aspirin. which laboratory value should be reported to the physician?

Potassium 3.6 mEq/L

Hematocrit 41%

PT 14 seconds

BUN 20 mg/dL

When a client takes aspirin. monitor for increases in PT (normal range 11.0-12.5 seconds in 85%-100%). Also monitor for possible decreases in potassium (normal range 3.5-5.0 mEq/L). If bleeding signs are noted. hematocrit should be monitored (normal range male 42%-52%. female 37%-47%). An elevated BUN could be seen if the client is having chronic gastrointestinal bleeding (normal range 10-20 mg/dL).

Explanation

When a client takes aspirin. monitor for increases in PT (normal range 11.0-12.5 seconds in 85%-100%). Also monitor for possible decreases in potassium (normal range 3.5-5.0 mEq/L). If bleeding signs are noted. hematocrit should be monitored (normal range male 42%-52%. female 37%-47%). An elevated BUN could be seen if the client is having chronic gastrointestinal bleeding (normal range 10-20 mg/dL).

2. What is the best way to schedule medication for a client with constant pain?

PRN at the client’s request

Prior to painful procedures

IV bolus after pain assessment

Around-the-clock

If the pain is constant. the best schedule is around-the-clock. to provide steady analgesia and pain control. The other options may actually require higher doses to achieve control

Explanation

If the pain is constant. the best schedule is around-the-clock. to provide steady analgesia and pain control. The other options may actually require higher doses to achieve control

3. A nurse is teaching a client with pancreatitis about following a low-fat diet. The nurse develops a list of high-fat foods to avoid and includes which food on the item list?

Chocolate milk.

Broccoli.

Apple.

Salmon.

Chocolate milk is a high-fat food.Options B and C: Fruits and vegetables are low in fat because they do not come from animal sources.Option D: Salmon is naturally lower in fat.

Explanation

Chocolate milk is a high-fat food.Options B and C: Fruits and vegetables are low in fat because they do not come from animal sources.Option D: Salmon is naturally lower in fat.

4. Which client(s) would be appropriate to assign to a newly graduated RN. who has recently completed orientation? (Choose all that apply.)

An anxious. chronic pain client who frequently uses the call button

A client second day post-op who needs pain medication prior to dressing changes

A client with HIV who reports headache and abdominal and pleuritic chest pain

A client who is being discharged with a surgically implanted catheter

A second day postoperative client who needs medication prior to dressing changes has predictable and routine care that a new nurse can manage. Although clients with chronic pain can be relatively stable. the interaction with this client will be time consuming and may cause the new nurse to fall behind. The client with HIV has complex complaints that require expert assessment skills. The client pending discharge will need special and detailed instructions.

Explanation

A second day postoperative client who needs medication prior to dressing changes has predictable and routine care that a new nurse can manage. Although clients with chronic pain can be relatively stable. the interaction with this client will be time consuming and may cause the new nurse to fall behind. The client with HIV has complex complaints that require expert assessment skills. The client pending discharge will need special and detailed instructions.

5. The nurse is giving dietary instructions on a client who is on a vegan diet. The nurse provides dietary teaching focus on foods high in which vitamin that may be lacking in a vegan diet?

Vitamin A.

Vitamin D.

Vitamin E.

Vitamin C.

Deficiencies in vegetarian diets include vitamin B12 which are found in animal products and vitamin D (if limited exposure to sunlight).Options A. C. and D are found in fruits and vegetables. which are eaten by a vegetarian.

Explanation

Deficiencies in vegetarian diets include vitamin B12 which are found in animal products and vitamin D (if limited exposure to sunlight).Options A. C. and D are found in fruits and vegetables. which are eaten by a vegetarian.

6. A client who is recovering from a surgery has been ordered a change from a clear liquid diet to a full liquid diet. The nurse would offer which full liquid item to the client?

Popsicle.

Carbonated beverages.

Gelatin.

Pudding.

Full liquid food items include items such as plain ice cream. sherbet. breakfast drinks. milk. pudding. and custard. soups that are strained. refined cooked cereals. and strained vegetable juices.Options A. B. and C are clear liquid diet.

Explanation

Full liquid food items include items such as plain ice cream. sherbet. breakfast drinks. milk. pudding. and custard. soups that are strained. refined cooked cereals. and strained vegetable juices.Options A. B. and C are clear liquid diet.

7. A nurse is caring for a client with Wernicke-Korsakoff syndrome. The physician asks the nurse to teach the client to consume thiamine-rich food. The nurse instruct the client to increase the intake of which food items?

Chicken.

Milk.

Beef.

Brocolli.

Food sources of thiamin include beef. liver. nuts. oats. oranges. pork. eggs. seeds. legumes. peas and yeast.Option A: Poultry contains niacin.Option B: Milk contains vitamins A. D. and B2.Option D: Broccoli contains folic acid. vitamins C. E. and K.

Explanation

Food sources of thiamin include beef. liver. nuts. oats. oranges. pork. eggs. seeds. legumes. peas and yeast.Option A: Poultry contains niacin.Option B: Milk contains vitamins A. D. and B2.Option D: Broccoli contains folic acid. vitamins C. E. and K.

8. A postoperative client has been placed on a clear-liquid diet. The nurse provides the client with which items that are allowed to be consumed on this diet?

Vegetable juices.

Custard.

Sherbet.

Bouillon.

A clear liquid diet consists of foods that are relatively transparent to light and liquid at room and body temperature. Foods allowed on the clear liquid diet (bouillon. popsicles. plain gelatin. ice chips. sweetened tea or coffee (no creamer). carbonated beverages. and water).Options A. B. and C are full liquid diet.

Explanation

A clear liquid diet consists of foods that are relatively transparent to light and liquid at room and body temperature. Foods allowed on the clear liquid diet (bouillon. popsicles. plain gelatin. ice chips. sweetened tea or coffee (no creamer). carbonated beverages. and water).Options A. B. and C are full liquid diet.

9. A family member asks you. "Why can't you give more medicine? He is still having a lot of pain." What is your best response?

“The doctor ordered the medicine to be given every 4 hours.”

“If the medication is given too frequently he could suffer ill effects.”

“Please tell him that I will be right there to check of him.”

“Let’s wait about 30-40 minutes. If there is no relief I’ll call the doctor.”

Directly ask the client about the pain and do a complete pain assessment. This information will determine which action to take next.

Explanation

Directly ask the client about the pain and do a complete pain assessment. This information will determine which action to take next.

10. Which client(s) are appropriate to assign to the LPN/LVN. who will function under the supervision of the RN or team leader? (Choose all that apply.)

A client who needs pre-op teaching for use of a PCA pump

A client with a leg cast who needs neurologic checks and PRN hydrocodone

A client post-op toe amputation with diabetic neuropathic pain

A client with terminal cancer and severe pain who is refusing medication

The clients with the cast and the toe amputation are stable clients and need ongoing assessment and pain management that are within the scope of practice for an LPN/LVN under the supervision of an RN. The RN should take responsibility for pre-operative teaching. and the terminal cancer needs a comprehensive assessment to determine the reason for refusal of medication.

Explanation

The clients with the cast and the toe amputation are stable clients and need ongoing assessment and pain management that are within the scope of practice for an LPN/LVN under the supervision of an RN. The RN should take responsibility for pre-operative teaching. and the terminal cancer needs a comprehensive assessment to determine the reason for refusal of medication.

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