NCLEX Practice Questions — Set 20
How to use this set
Run it as a timed block rather than dipping in and out. 100 items at roughly a minute each is close to the pace the real exam asks for, and pacing is a skill that only improves under a clock. Answer every item before you open a single rationale — checking as you go turns a test into a reading exercise and hides the questions you were unsure about.
These sets are numbered rather than sorted by subject. The questions come from a general NCLEX bank that carries no topic field, and labelling them by eye would put a share of them under the wrong heading, so they are presented as mixed sets — which is how the exam itself arrives.
The 100 questions
The registered nurse delegates which of the following nursing tasks to unlicensed assistive personnel?
Show answer and rationale
Correct answer: A. Walk a client who has an ankle sprain to the bathroom
Unlicensed assistive personnel cannot reinforce instruction or provide instruction. Performing active range-of-motion exercises on a client who had a hip arthroplasty is not an appropriate job assignment for unlicensed assistive personnel, and active range of motion is likely to dislocate the hip (particularly adduction). Unlicensed assistive personnel may walk a client who has an ankle sprain to the bathroom.
Which of the following crutch gaits should the nurse instruct the client to use who has bilateral paralysis of the hips and legs?
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Correct answer: B. Swing-to gait
A swing-to gait is a crutch gait that is used by clients who have paralysis of the hips and legs or wear bilateral braces on the legs. A fourpoint gait may be used by arthritic clients. A three-point gait may be used by a client with a broken leg or sprained ankle. A two-point gait requires more weight bearing on each foot. It is a faster crutch gait than a four-point gait.
Which of the following should the nurse include when instructing a client with crutches on the two-point gait?
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Correct answer: B. Move the left crutch and right foot forward together, followed by moving the right crutch and the left foot forward together
When using the two-point gait, the left crutch and right foot are moved forward together, followed by moving the right crutch and left foot forward together. The crutch walk requires some weight bearing on each foot. During the four-point gait, the right crutch is moved forward followed by the left foot, then the left crutch is moved forward followed by the right foot. This is the most stable of all crutch walks. It provides the most support while requiring weight bearing on both legs. This gait may be used for some types of paralysis, such as in children with cerebral palsy. In the three-point gait, both crutches are moved forward with the weaker leg, followed by moving the stronger leg forward. In this gait, the client is required to bear all weight on the unaffected leg. In the swing-to gait, both crutches are moved forward together followed by bringing the legs through beyond the crutches. This gait is used by clients who have a paralysis of their lower extremities.
The nurse is teaching a class on urinary infections. Which of the following should the nurse include?
Show answer and rationale
Correct answer: A. E. coli is the most common cause of urinary infections
E. coli is the most common organism causing urinary infections. The urinary tract above the urethra is sterile. Pyelonephritis is an infection of the kidneys or upper urinary tract. The incidence of urinary tract infections is greater in the female because the urethra is shorter than that of the male and also is closer to the vagina and rectum.
The nurse assesses a client’s hourly output of urine to be 70 ml. Which of the following is the most appropriate action by the nurse?
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Correct answer: B. Recognize this as a normal hourly output
The average 24-hour daily output for an adult is approximately 1500 ml or 62.5 ml per hour, so 70 ml is considered normal and no further action is necessary.
The nurse instructs a client with pyelonephritis to drink 3000 ml of fluids per day. The nurse understands that the rationale for this intervention is to
Show answer and rationale
Correct answer: A. prevent stasis of urine.
Increasing the fluid intake promotes the flushing out of the urinary tract and prevents stasis of urine. Preventing reflux of urine and decreasing urinary output or residual urine do not provide rationales for increasing fluid intake in pyelonephritis.
The nurse is teaching a class on renal disease. Which of the following should the nurse include?
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Correct answer: C. Acute renal failure follows prolonged hypotension
Acute renal failure does occur after prolonged hypovolemia or hypotension. Involvement of 95% of the nephrons is found in end-stage renal disease. There is no direct correlation between the amount of urine produced and the severity of renal failure. Even though acute renal failure is often associated with a urinary output of less than 400 ml per day, it is possible to have a normal or even an increased urinary output. Creatinine is the most diagnostic test for renal failure.
The nurse administers which of the following prescribed medications to a client with recurrent urinary tract infections caused by Escherichia coli?
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Correct answer: B. Sulfamethoxazole and trimethoprim (Bactrim DS)
Sulfamethoxazole and trimethoprim (Bactrim DS) is an antibiotic and a drug of choice in the treatment of urinary tract infections. Hyoscyamine sulfate (Levsin) is an anticholinergic used in specific spastic disorders. Bethanechol chloride (Urecholine) is a cholinergic agonist used in urinary retention. Phenazopyridine hydrochloride (Pyridium) is a urinary analgesic given to produce an analgesic effect on the urinary mucosa.
The nurse is caring for a client experiencing renal colic associated with nephrolithiasis. Which of the following nursing measures should receive priority in the client’s plan of care?
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Correct answer: C. Administer morphine sulfate
Straining the urine, monitoring intake and output, and encouraging ambulation are all appropriate interventions in the management of renal calculi, but administering an analgesic is the priority intervention for a client experiencing renal colic. Renal colic is an excruciating pain that occurs when a stone passes into the ureter.
The nurse is caring for a client suspected of sustaining renal trauma following an automobile accident. It is a priority that the nurse monitor and report which of the following findings?
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Correct answer: A. Hematuria
When monitoring a client for hematuria who has sustained a renal trauma, it is important to detect hemorrhage, which can be a life-threatening complication.
The nurse is caring for a client in acute renal failure. Which of the following clinical manifestations is a priority for the nurse to monitor in this client?
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Correct answer: C. Infection
The nurse should closely monitor a client in acute renal failure for the presence of an infection, which constitutes the greatest risk for mortality. The incidence may be as high as 70% in clients who developed acute renal failure resulting from an infection following trauma or surgery. Pain is generally not a clinical manifestation in acute renal failure. Although a client may die from oliguria, it is generally reversible and the mortality rate is approximately 50%. Anemia occurs in chronic, not acute, renal failure.
The nurse is caring for a client in acute renal failure. Which of the following would indicate to the nurse that the client is uremic?
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Correct answer: D. BUN of 32 mg/dl
An elevated BUN, or increased nitrogenous wastes in the blood, is classic uremia in a client in acute renal failure. A normal BUN is 10 to 20 mg/dl. A serum calcium of 10.5 mg/dl and a urine specific gravity of 1.030 are at the upper range for normal calcium (9 to 10.5 mg/dl) and specific gravity (1.010 to 1.030). A serum potassium of 2.8 mg/dl is low (3.5 to 5.5 mEq/L) and is not indicative of acute renal failure.
The nurse is preparing a client for an intravenous pyelogram (IVP). Which of the following would be essential for the nurse to include?
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Correct answer: D. Administer a laxative the night before the procedure
Administering a laxative the evening before an IVP is correct. Fasting for 8 hours is required. There is no fasting before a KUB (kidneys, ureters, bladder) x-ray. Inserting a ureteral catheter occurs during a retrograde pyelogram, not an IVP. Bladder spasms occur after a retrograde pyelogram, not an IVP.
The nurse identifies which of the following hospitalized clients to be at greatest risk for the development of a nosocomial urinary tract infection?
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Correct answer: C. A 75-year-old male who has pancreatic cancer
Although nosocomial urinary infections may occur in any hospitalized client, the incidence is significantly impacted by the client’s overall state of health. A client who is male, older, and has a terminal cancer and is receiving chemotherapy is immunosuppressed and at the greatest risk.
The nurse correctly collects urine by which of the following methods to establish the diagnosis of urethritis?
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Correct answer: C. Obtain a specimen in the beginning and in the middle of the urine flow
Obtaining a urine specimen in the beginning and again in the middle of the urine flow (split urine collections) for the purpose of performing a culture is the correct procedure for diagnosing urethritis.
The nurse identifies which of the following diagnostic laboratory tests as the one the nurse should assess first to establish a diagnosis for renal disease?
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Correct answer: B. Serum creatinine
Although serum potassium, uric acid, and blood urea nitrogen are all useful diagnostic tests in the diagnosis of renal disease, the serum creatinine is the most diagnostic.
The nurse is collecting a nursing history from a client admitted with acute pyelonephritis. Which of the following questions should the nurse ask?
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Correct answer: D. "Do you have pain when urinating?"
Dysuria, or painful urination, does occur in acute pyelonephritis. Blood in the urine and dribbling at the end of urinating are not clinical manifestations. An increased urinary output, and not a decreased output, occurs in pyelonephritis.
The nurse identifies which of the following clients to be at greatest risk for the development of struvite calculi?
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Correct answer: B. A female with a urinary tract infection
Women who experience frequent urinary tract infections are more likely to develop struvite calculi that take on a staghorn appearance from repeated Proteus urinary tract infections. A Jewish male with a history of gout is at risk for uric acid calculi. A male with idiopathic hypercalcuria is at risk for calcium oxalate. A female with an autosomal recessive defect is at risk for cystine calculi.
When preparing a client for a renal biopsy, it would be essential for the nurse to explain which of the following aspects of the procedure?
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Correct answer: B. Inform the client that prior to the procedure, typing and cross-matching blood will be done
A client scheduled for a renal biopsy will routinely be typed and cross-matched for blood because of the risk of bleeding. The insertion of a catheter and installation of saline solution into the bladder occur with a cystometrogram. Burning on urination is an anticipated outcome following a cystoscopy. Administering an enema or cathartic before the procedure may occur with several procedures, such as intravenous pyelography, retrograde pyelogram, or a cystoscopy.
The nurse monitors an increased incidence of stress incontinence in a client during which of the following activities?
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Correct answer: B. Laughing
Stress incontinence occurs during periods of increased abdominal pressure such as that which occurs with laughing. Eating, sleeping, and walking do not alter the abdominal pressure.
After inserting an indwelling Foley catheter, the nurse begins to inflate the balloon and the client complains of pain. Which of the following would be the priority action for the nurse to implement?
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Correct answer: C. Aspirate back solution from the balloon and advance the catheter further
When a client complains of pain during inflation of the balloon after inserting an indwelling catheter, the nurse should aspirate back the inserted solution and advance the catheter further to ensure the catheter is in the bladder and not lodged in the urethra.
Which of the following principles of catheter care should the nurse consider before catheterizing a client?
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Correct answer: B. Use catheterization as a last resort
Catheterization may be used as a last resort after all noninvasive measures to promote urination, such as encouraging ambulation and fluids, have failed. Catheterization should never be used for clients who are geriatric to prevent urinary incontinence. The catheter bag should always be kept below the level of the bladder. Powder should never be applied to the perineal area and around the catheter insertion site, because this practice promotes infection.
The nurse evaluates a client with a diagnosis of dehydration to have which of the following specific gravity readings?
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Correct answer: D. 1.035
Normal specific gravity is 1.003 to 1.030. An elevated specific gravity occurs with albuminuria, glycosuria, and dehydration. A decreased specific gravity occurs with diabetes insipidus.
The nurse is reviewing the normal limits for a urinalysis. Which of the following findings would indicate to the nurse the need for additional investigation?
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Correct answer: D. Dark, amber-colored urine
Normal urine specific gravity is 1.003 to 1.030. Normal urine pH is 4.0 to 8.0. Urine is normally yellow in color and faint in odor. Dark, amber-colored urine may indicate dehydration, infection, or blood in the urine.
Which of the following should the nurse include to correctly collect a timed urine specimen?
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Correct answer: D. Encourage the client to empty the bladder and save this specimen at the end of the collection time
The first voided specimen for a timed urinary test should be discarded. The collection container should be kept in the refrigerator or on ice in the bathroom. If a urine specimen is missed, the whole timed test must start again. It is helpful to have a sign on the bathroom door and above the toilet to save all urine. At the conclusion of the test, the client should be encouraged to empty the bladder and save this specimen.
A client asks the nurse, "Does everyone who gets cancer die of it?" The nurse’s best response is based on which of the following?
Show answer and rationale
Correct answer: C. About 5�million people in the United States survive cancer for 5 or more years
Over 1�million Americans are diagnosed with cancer each year. However, only 500,000 die annually and approximately 5�million are cancer-free for 5 or more years. Heart disease, not cancer, is the leading cause of adult death in the United States.
The client states, "I heard that all men get prostate cancer sometime in their lives." In teaching the client about cancer incidence, the best response is based on which of the following?
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Correct answer: C. Prostate cancer is the most frequently diagnosed cancer in men
Prostate cancer is the most common cancer in U.S. men, with lung cancer being second. The incidence of prostate cancer is significantly higher in black men worldwide. Screening is available for prostate cancer.
When planning the discharge of a client with cancer, which of the following should the nurse include as a priority?
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Correct answer: B. Information on stress reduction techniques
Reducing stress in a person’s life is one of the recommended methods of cancer risk reduction. Clients with cancer are at a higher risk of a new cancer or recurrence, and therefore should be instructed in risk-reduction methods. Limiting alcoholic beverages is encouraged to reduce cancer risk, but it is not required that the client abstain completely unless there are other medical reasons to do so. Not all clients will require home or hospice care after discharge, as many clients with cancer lead long, productive lives.
While assessing a client’s skin, the nurse should report which of the following findings as a possible skin cancer?
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Correct answer: B. A blue-black appearing mole
A blue-black appearing mole is one of the cardinal signs of melanoma skin cancer. Red, swollen plaques, bull’s-eye rash, and spider angiomas are not indicative of skin cancer, but other dermatologic abnormalities.
The nurse is collecting a health history on a client admitted for colon cancer. Which of the following questions would be a priority to ask this client?
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Correct answer: A. "Have you noticed any blood in the stool?"
Although early colon cancer is asymptomatic, occult or frank blood in the stool is often an assessment finding in a client diagnosed with colon cancer. If pain is present, it is usually lower abdominal cramping. Constipation and diarrhea are more frequent findings than nausea, and ascites is more likely to be present in very advanced disease stages of ovarian and liver cancers.
A nurse is educating a group of clients on cancer screening practices. Which of the following instructions should the nurse include as a recommended screening pattern?
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Correct answer: D. Annual cancer check-ups for all persons over age 40
Nationally recognized cancer screening guidelines recommend everyone over age 40 visit the doctor annually for cancer assessment. Pap and pelvic examinations and screening for cervical and uterine cancer should begin at age�18. Mammographic screening for breast cancer is not recommended on an annual basis until at least age 40, and colorectal screening is recommended beginning at age 50, with colonoscopy only every 5 to 10�years.
The client with cancer states, "My pain is a 10!" on a 0-to-10 scale (10 being worst possible pain). Which of the following is the appropriate nursing intervention?
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Correct answer: A. Assure that a strong opioid, nonopioid, and adjuvant are ordered and administer per order
Fewer than 1% of clients become addicted to narcotic analgesics when used appropriately for pain management; therefore, in this case, addiction should not be a concern. Narcotic doses can be increased as pain increases, and therefore do not need to be reserved for fear of using them too early. Meperidine (Demerol) is seldom used to treat cancer pain because of metabolites that accumulate with continued use. If this is ordered, the nurse should consult with the physician regarding a change. According to the World Health Organization analgesic ladder for pain management, severe pain should be treated with a strong opioid (e.g., morphine), with a nonopioid analgesic (e.g., acetaminophen), and an adjuvant (e.g., nonsteroidal anti-inflammatory).
In planning the care of a client experiencing fatigue related to chemotherapy, which of the following is the most appropriate nursing intervention?
Show answer and rationale
Correct answer: A. Prioritize and administer nursing care throughout the day
Clients should be taught to pace their activities throughout the day in order to conserve energy; therefore, nursing care should be paced as well. Fatigue is the most common side effect of cancer and its treatment; therefore, it needs to be appropriately managed. Although adequate sleep is important, maximal sleep will not completely resolve clinical manifestations. Completely restricting visitors does not promote healthy coping and may result in isolation.
The nurse is caring for a client who underwent a bone marrow transplant 10 days ago. The nurse should monitor the client for which of the following clinical manifestations that indicates a potentially life-threatening situation?
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Correct answer: C. Mild temperature elevation
During the first 100 days posttransplant, clients are at high risk for life-threatening infections. This is especially true prior to marrow engraftment, which occurs at approximately 2 to 3 weeks posttransplant. The earliest sign of infection in an immunocompromised client may be a mild fever. Mucositis, confusion, and depression are possible clinical manifestations but represent less life-threatening complications.
Six days after receiving chemotherapy, the client reports that, "My mouth feels like it’s on fire!" Which of the following is the priority nursing action?
Show answer and rationale
Correct answer: A. Assess the oral mucosa for signs of infection and tissue breakdown
Adverse reactions of chemotherapy include stomatitis and mucositis in some clients. The nurse should always first assess the client’s oral mucosa for signs of breakdown and infection. Pain medication may be necessary to administer, but this is not the first action the nurse should take. Rinsing the oral mucosa is encouraged, but with salt or soda solution, not over-the-counter mouthwashes, which can be drying. Clients should eat small, frequent meals of soothing foods after chemotherapy, but usually this is not required after the first week, and, again, the nurse should perform an assessment before implementing a plan of care.
The nurse finds the client vomiting on the second day after chemotherapy. Antiemetics and IV fluids have been administered as ordered. The nurse should include which of the following as an appropriate intervention for this client?
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Correct answer: D. Offer music therapy to decrease nausea
The addition of complementary therapies, such as music therapy, relaxation techniques, distraction, and imagery, has been shown to provide additional relief from nausea and vomiting. The client should remain in an upright position after eating, but 30 minutes is usually sufficient. A tube feeding would be inappropriate because nausea and vomiting after chemotherapy are usually short-term problems, after which the client will be able to return to normal eating patterns. Unless extremely severe and unmanageable, it would not be appropriate to decrease the dose of chemotherapy at the next administration.
In preparing a client on oral narcotic analgesics for discharge after a mastectomy, the nurse should include which of the following in postoperative teaching?
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Correct answer: A. Bowel-training program
Surgery, narcotic analgesics, and client immobility promote constipation postoperatively. Therefore, clients should be instructed in a bowel-training program that includes use of suppositories or oral stool softener as needed, physical activity such as walking, and intake of fruits, fiber, and fluid. Oral narcotics should be used as needed for pain while managing the adverse reaction of constipation. The diet should be high in fiber, not necessarily protein. A weight-training program would not be appropriate until surgical drains are removed, although use of the affected side with gentle arm motion is advocated.
While caring for the client with superior vena cava syndrome, the nurse should include which of the following interventions?
Show answer and rationale
Correct answer: B. Elevate the head of the bed
Superior vena cava syndrome is compression of the superior vena cava by enlarged lymph nodes, clot, or tumor, thus restricting the flow of blood out of the head, neck, and upper extremities. This results in swelling of these areas and shortness of breath. Elevating the head of the bed decreases the pressure in the head and upper body by allowing gravity to assist in blood flow. The client should not perform Valsalva’s maneuver, as this increases that pressure. The client will be anxious about this, so providing resources to decrease anxiety, including supportive friends and family, would be advocated. Chemotherapy or radiation to decrease the size of a tumor or lymph node is one of the treatments for superior vena cava syndrome, so chemotherapy should be administered as ordered, and not withheld.
The nurse is caring for a client with small-cell lung cancer. Which of the following observations would be a priority that the nurse should report immediately?
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Correct answer: C. Serum sodium less than 130 mEq/L
Clients most at risk for syndrome of inappropriate antidiuretic hormone (SIADH) are those with small-cell lung cancer, as well as several other cancers. Therefore, the nurse should be alert for clinical manifestations of this, such as weight gain, decreased urinary output, and dilutional hyponatremia. Headache may occur, but this is not a common clinical manifestation of SIADH.
The nurse is caring for a client who received chemotherapy for leukemia 24 hours ago and is now complaining of flank pain. The client’s urinary output has decreased to less than 30 ml/hour. The nurse evaluates which of the following conditions as the most likely cause of the client’s clinical manifestations?
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Correct answer: C. Tumor lysis syndrome
Tumor lysis is most common in clients who have received chemotherapy for leukemia lymphoma, or small cell lung cancer, within 24 to 48 hours of administration. Flank pain is a clinical manifestation of renal failure associated with tumor lysis syndrome. Flank pain is not a typical clinical manifestation of syndrome of inappropriate antidiuretic hormone (SIADH), superior vena cava syndrome, or hypercalcemia.
The nurse should instruct a client that which of the following is the most effective prevention against bladder cancer?
Show answer and rationale
Correct answer: A. Stop smoking
Persons at greatest risk for bladder cancer are Caucasian men over 50�years of age who have had occupational exposures to dyes, rubber, and leather industries, and who smoke. Because age, race, and occupation are not alterable, the best alternative is to stop smoking. Clients should be provided with smoking cessation information and support to reduce their risk of several cancers and other health problems.
Which of the following should the nurse include in the preoperative care plan of a client with head and neck cancer?
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Correct answer: D. Instruct the client and family in communicating with a picture board
Surgery is the primary treatment for head and neck cancer and may involve removal of part of the tongue, larynx, and other structures. This surgery is often disfiguring and often makes eating and communicating with staff and family very difficult. Losses can lead to difficulties in coping, so nursing interventions to lessen losses and promote coping (such as communicating with a picture board) have a major role for the nurse in this setting. Mouthwash should not be used because it is drying to the oral mucosa. Smoking should be highly discouraged; it is one of the leading risk factors for this cancer and it dries the oral mucosa. The diet for this client should be developed in collaboration with the physician and therapists and often includes tube feeding followed by soft mechanical diet, due to swallowing difficulties. Unfortunately, the client will not be able to have favorite foods for a while.
A client who has been treated for lung cancer returns to the clinic and during the nursing assessment reports recent problems with balance and memory. Based on the nurse’s understanding of lung cancer, the appropriate action would be which of the following?
Show answer and rationale
Correct answer: C. Perform a more thorough assessment
Lung cancer often metastasizes to the brain, causing neurologic symptoms as the client is describing. Providing reassurance is minimizing the client’s concerns, and making recommendations for herbal supplements without a thorough assessment is not an appropriate nursing intervention. The client is not in immediate danger, so calling an ambulance is not appropriate either.
The spouse of a client with early-stage prostate cancer asks the nurse, "Why isn’t the physician treating my husband’s cancer?" The nurse’s best response should be based on which of the following?
Show answer and rationale
Correct answer: B. Watchful waiting is often appropriate for men over age 70
Prostate cancer is very slow growing in older men, and therefore no intervention is recommended. "Watchful waiting" is appropriate for men over age 70 with small, early-stage cancers. Transurethral resection of the prostate and external beam radiation are used to treat advanced disease. The client may be receiving hormonal therapy, but it is primarily used for advanced disease.
While performing a nursing assessment, a female client informs the nurse of vague abdominal discomfort, bloating, and unexplained indigestion and flatulence for the last few months. What should the nurse ask in order to elicit the most important information for completing the assessment?
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Correct answer: C. "Tell me about your family’s medical history."
Vague abdominal discomfort, bloating, and unexplained indigestion and flatulence are unfortunately the only clinical manifestations of ovarian cancer, and the reason it is often overlooked. Therefore, to more thoroughly complete the assessment, the nurse should take a complete family cancer history to aid in determining the client’s risk of ovarian cancer. Women with a family history of ovarian cancer are at higher risk. If anything, the client would probably be gaining weight, not losing, from abdominal ascites. Unusual menstrual bleeding is an important clinical manifestation related to uterine, rather than ovarian, cancer.
A nurse is teaching a class on breast selfexamination. Which of the following should the nurse include in the class?
Show answer and rationale
Correct answer: D. Include both inspection and palpation of the breast in the exam
Breast self-exam should include inspection of the breasts in front of a mirror. According to national authorities, it should also include palpation using light, medium, and deep pressure with the pads of the first three fingers (not the fingertips) while in the shower and while lying down. It is not necessary to perform the palpation exam in front of a mirror.
A client states, "I’m worried about being burned by radiation therapy." The most appropriate response is based on the nurse’s understanding that
Show answer and rationale
Correct answer: B. burns are very rare with today’s technology.
The equipment and techniques used to deliver radiation therapy today very rarely result in skin burns. Local skin reaction such as redness, dryness, desquamation, and irritation may occur. These reactions occur most often in fairskinned persons, and are potentially worse if there are oils on the skin from hand lotion, soap, or deodorant; therefore, application of these is discouraged. Washing the area receiving radiation with plain water and patting dry is preferred to strong soap.
When planning care for a client being treated for cervical cancer, it would be a priority for the nurse to include which of the following in the plan of care?
Show answer and rationale
Correct answer: A. Assessment of sexual function
Surgery and radiation therapy for cervical cancer often result in shortening of the vagina, vaginal dryness, and loss of libido due to emotional issues related to sexuality and femininity. Therefore, the client’s feelings about sexuality and the partner’s feelings should be assessed. If a client is not sexually active, instructions should be given in the use of a vaginal dilator and lubricant to prevent adhesion of the vaginal walls. Although instruction about birth control methods may be needed for some clients, treatment for cervical cancer may include total abdominal hysterectomy, so this would not be appropriate for all clients. Encouraging fluids and daily weights are not priorities in cervical cancer care.
The registered nurse is making out the nursing tasks for the day. Which of the following nursing tasks may be delegated to a licensed practical nurse?
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Correct answer: A. Administer prescribed anticonvulsant to prevent seizure in a client who has a central nervous system tumor
Syndrome of inappropriate antidiuretic hormone (SIADH), tumor lysis syndrome, and hypercalcemia are all oncology medical emergencies, requiring the attention of a registered nurse. Administering an IV solution, assessing for an electrolyte imbalance, and monitoring the serum calcium are all nursing tasks reserved for the registered nurse. Hypercalcemia is also an oncology medical emergency, so monitoring the serum calcium is a nursing task reserved for the registered nurse. A licensed practical nurse may administer an anticonvulsant to a client who has a central nervous system tumor.
The nurse is teaching a class on breast cancer. Which of the following should the nurse include as risk factors?
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Correct answer: B. Menarche at an early age and nulliparous
Risk factors for breast cancer include being white over being nonwhite. The incidence of breast cancer is higher in obese females. Additional risk factors include menarche at an early age and being nulliparous.
Which of the following findings on a female breast exam should the nurse report as suspicious of breast cancer?
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Correct answer: A. A poorly defined, firm lump that is nontender and fixed to the skin
A poorly defined, firm lump that is nontender and fixed to the skin is characteristic of breast cancer.
The nurse is admitting a client with vaginal cancer. Which of the following questions should the nurse ask to elicit the most likely causative factor?
Show answer and rationale
Correct answer: B. "Did your mother take diethylstilbestrol (DES) during pregnancy?"
A client whose mother had taken diethylstilbestrol (DES) during pregnancy is more likely to develop vaginal cancer. There is no correlation with the age of the first menses, having taken tamoxifen, or having had a history of a sexually transmitted disease.
The nurse should instruct a female client that the best time to perform a breast self-examination is which of the following?
Show answer and rationale
Correct answer: D. The last day of the menstrual period
The best time to perform a breast selfexamination is the last day of the menstrual period.
Which of the following instructions should the nurse give a male client on how to perform a testicular self-examination (TSE)?
Show answer and rationale
Correct answer: D. The best time to examine the testicle is after a shower
The best time to perform a testicular selfexamination is after a shower. The warmth of the shower causes the testes to position themselves lower in the scrotum. The testes should be examined by both hands by rolling each testis between the thumb and first three fingers until the surface has been covered. The examination should be performed each month at a consistent time such as the first of the month.
The nurse making a care plan for a client with severe thrombocytopenia should include which of the following?
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Correct answer: D. Avoid intramuscular administration of medications
Severe thrombocytopenia is a platelet count of , 10,000 to 20,000/mm3 . The client with this low number of platelets is at great risk of bleeding from any invasive procedure. Intramuscular injections can cause a hematoma in the muscle and should be avoided if possible. A lumbar puncture would put the client at an unnecessary risk of bleeding. A private room is not indicated unless there are other reasons for isolation (infection, neutropenia). Furosemide is a diuretic and not used as therapy for thrombocytopenia.
A client with lung cancer is admitted with a new diagnosis of acute disseminated intravascular coagulation (DIC). Which of the following actions is a priority?
Show answer and rationale
Correct answer: B. Assess the client for any indications of internal or external bleeding
Acute disseminated intravascular coagulation (DIC) is a serious disorder resulting in bleeding and clotting. It is a priority that the client must be assessed frequently by the nurse for bleeding. After ensuring that there is no active bleeding, the nurse may obtain a detailed diet history or implement family teaching. A delay to do family teaching away from the client or to dwell on diet history would not be appropriate. Some clients with chronic DIC may eventually require dialysis.
The nurse has instructed a client with a hematological disorder about the functions of the hematologic system. The client indicates a need for further teaching by describing the function of the hematologic system as
Show answer and rationale
Correct answer: A. "the exchange of oxygen and carbon dioxide at the alveoli."
Oxygen and carbon dioxide are transported in the blood. Air exchange occurs in the lungs, which are a part of the respiratory system. The blood also contains substances that help to form clots and mount immune responses to infectious agents.
The nurse is discharging a client with aplastic anemia. Which of the following statements made by the client would demonstrate the need for additional teaching by the nurse?
Show answer and rationale
Correct answer: C. "I’m going back to my job in the toddler room at a day care center tomorrow."
A client newly treated for aplastic anemia may be immunocompromised for weeks, at risk of bleeding, and fatigued. Returning to work in a day care center may be unrealistic and risky to the client. The nurse should be sure the client and family understand the risks before discharge.
The nurse is evaluating a client with an enlarged spleen. Which of the following diagnostic tests would confirm the diagnosis?
Show answer and rationale
Correct answer: D. CAT scan of the abdomen
Complications from an enlarged spleen can be reflected in the complete blood count. Cell morphology may be abnormal in certain conditions that are associated with splenomegaly. The spleen is located in the abdomen, and visualization of the spleen and surrounding structures with a CAT scanner may be helpful in finding an etiology.
The nurse has started a transfusion of packed red blood cells. The nurse should immediately stop the transfusion when which of the following occurs?
Show answer and rationale
Correct answer: A. Fever and back pain
Fever and back pain can occur in hemolytic blood transfusion reaction caused by the mismatch of blood types. If the transfusion is not stopped immediately, the client could go into shock and die. Dry mouth could be caused by an antihistamine given as a premedication or from dehydration, but it is not a reason to stop the transfusion. Blood products expire in a few hours and interruptions should be minimized. A heart beat of 74 beats per minute is not too high or too low. The client may also spike a temperature and have flushed skin.
The nurse is caring for a client with neutropenia. Which of the following blood tests would indicate to the nurse the desired response to treatment?
Show answer and rationale
Correct answer: D. Increased granulocytes
Neutropenia is an abnormally low white blood cell or granulocyte count. The goal of treatment would be an increase in the granulocyte count. Platelets, hemoglobin level, and liver function test changes may indicate response to some treatments, but are not measures of neutrophil count.
Which of the following is essential for the nurse to assess in the health history of a client with a hematologic disorder?
Show answer and rationale
Correct answer: C. The client’s menstrual history
A woman’s reproductive history can help explain if the client is anemic from an abnormal menstrual flow. Transfusion reactions (alloimmunization from multiple pregnancies) may also occur. Occupation, recreational activities, and travel to Canada would have little relevance to the hematologic health history.
A student nurse is reviewing the chart of a client with a long-standing anemia. The student asks the nurse what the term koilonychias means. The nurse should inform the student that koilonychias means the
Show answer and rationale
Correct answer: C. fingernails are spoon-shaped.
Spoon-shaped fingernails, or koilonychias, is a sign of long-standing chronic anemia.
A client returns to the clinic after a procedure complaining of pain in the left lower back. The nurse suspects the client most likely is experiencing
Show answer and rationale
Correct answer: D. a hematoma from a bone marrow biopsy and aspiration performed 2 days ago.
The most common site for biopsy and aspiration of the bone marrow is the posterior iliac crest bone. A hematoma from inadequate pressure applied to the site postprocedure could cause pain. Splenomegaly does not cause pain in this area and does not result from a Schilling test for pernicious anemia. Hepatitis from a blood transfusion would typically take weeks to cause symptoms, and pain in this specific site is unlikely. Folic acid deficiency is not painful and usually is the result of poor dietary intake and not of a procedure.
A client with an enlarged lymph node in the neck is scheduled to have an open biopsy of the node. Which of the following client statements would alert the nurse to an inadequate understanding of the procedure?
Show answer and rationale
Correct answer: A. "They are going to find cancer and I have to stay in the hospital overnight."
Open biopsies of lymph nodes may be done in the operating room under local anesthesia. The client may be told to be NPO as a precaution. The client should be able to go home that same day if someone else drives. The biopsy is being done to determine why the lymph node is swollen. Cancer could be found on a lymph node biopsy, but there may be other causes of an enlarged node. Usually the pathological results are available within 2 days.
The admitting nurse is making room assignments for a client admitted with aplastic anemia. The nurse appropriately selects which of the following room assignments for this client?
Show answer and rationale
Correct answer: A. Private room, protective isolation, and HEPA filtration
The aplastic anemia client has neutropenia and needs protection from other clients and staff. A private room with protective isolation and special air filtration is ideal.
During an IV antibiotic administration, the nurse inspects a 2-day-old IV site on a client who is neutropenic and observes redness without swelling. The client complains of tenderness. Which of the following interventions is the priority for the nurse to implement?
Show answer and rationale
Correct answer: A. Inform the client that the IV will need to be changed to a new site
A client who is neutropenic is susceptible to infection. In the absence of white blood cells, the inflammatory response to infection and the ability to produce pus is suppressed. Redness and pain may be the only clinical manifestations. Changing the 2-day-old IV site is appropriate. Vital signs may further indicate infection if abnormal, but not always. Administering pain medications will ease the pain but not the infection, which could become rapidly severe. Notifying the physician is not a priority.
A client with iron deficiency anemia is very pale, has shortness of breath, and records a hemoglobin level of 7.5 grams. Which of the following is a priority for the nurse to implement?
Show answer and rationale
Correct answer: A. Administer packed red blood cells
A client with a hemoglobin of 7.5 grams classifies as severe anemia. The client is symptomatic and the administration of packed red blood cells is the priority. Administering an iron supplement, instructing the client on a diet high in iron, and conserving energy are all important interventions but not the priority.
During a therapeutic phlebotomy of a client with hemochromatosis, the nurse explains the rationale for the procedure by telling the client which of the following?
Show answer and rationale
Correct answer: D. "You may need several phlebotomies during your lifetime to keep the iron from damaging your pancreas and heart."
Hemochromatosis is a genetic disorder that may require periodic series of phlebotomies to remove iron from the body. The purpose is not to save the blood for later transfusion back to the client. Diet cannot cause the disease. Having too much blood does not cause infections.
The nurse should monitor a client with blood type A who received a transfusion from a type O donor for which of the following?
Show answer and rationale
Correct answer: B. An expected rise in hemoglobin and hematocrit
The type O blood would not cause a febrile transfusion reaction because it contains neither A nor B antigens to which the recipient’s antibodies react. Type O is a universal donor for this reason. Nothing in the case was mentioned about the Rh status of the donor or recipient, thus no conclusion about this can be made. A fluid overload reaction is caused by volume and rate of transfusion, not by the blood type.
The nurse evaluates which of the following clients to be at risk for developing hypernatremia?
Show answer and rationale
Correct answer: B. 50-year-old with pneumonia, diaphoresis, and high fevers
Diaphoresis and a high fever can lead to free water loss through the skin, resulting in hypernatremia. Loop diuretics are more likely to result in a hypovolemic hyponatremia. Diarrhea and vomiting cause both sodium and water losses. Clients with syndrome of inappropriate antidiuretic hormone (SIADH) have hyponatremia, due to increased water reabsorption in the renal tubules.
A client is admitted with diabetic ketoacidosis who, with treatment, has a normal blood glucose, pH, and serum osmolality. During assessment, the client complains of weakness in the legs. Which of the following is a priority nursing intervention?
Show answer and rationale
Correct answer: B. Ensure the client is safe from falls and check the most recent potassium level
In the treatment of diabetic ketoacidosis, the blood sugar is lowered, the pH is corrected, and potassium moves back into the cells, resulting in low serum potassium. Client safety and the correction of low potassium levels are a priority. The weakness in the legs is a clinical manifestation of the hypokalemia. Dairy products and green, leafy vegetables are a source of calcium.
A client with a potassium level of 5.5 mEq/L is to receive sodium polystyrene sulfonate (Kayexalate) orally. After administering the drug, the priority nursing action is to monitor
Show answer and rationale
Correct answer: A. bowel movements.
Kayexalate causes potassium to be exchanged for sodium in the intestines and excreted through bowel movements. If client does not have stools, the drug cannot work properly. Blood pressure and urine output are not of primary importance. The nurse would already expect changes in T waves with hyperkalemia. Normal serum potassium is 3.5 to 5.5 mEq/L.
A client is receiving an intravenous magnesium infusion to correct a serum level of 1.4 mEq/L. Which of the following assessments would alert the nurse to immediately stop the infusion?
Show answer and rationale
Correct answer: A. Absent patellar reflex
An intravenous magnesium infusion may be used to treat a low serum magnesium level. Normal serum magnesium is 1.5 to 2.5 mEq/L. Clinical manifestations of hypermagnesemia are the result of depressed neuromuscular transmission. Absent reflexes indicate a magnesium level around 7 mEq/L. Diarrhea and PVCs are not clinical manifestations of high magnesium levels. Hypermagnesemia causes hypotension.
A client with chronic renal failure reports a 10-pound weight loss over 3�months and has had difficulty taking calcium supplements. The total calcium is 6.9 mg/dl. Which of the following would be the first nursing action?
Show answer and rationale
Correct answer: D. Check to see if a serum albumin level is available
A client with chronic renal failure who reports a 10-pound weight loss over 3�months and has difficulty taking calcium supplements is poorly nourished and likely to have hypoalbuminemia. A drop in serum albumin will result in a false low total calcium level. Placing an IV is not a priority action. Depressed reflexes are a sign of hypercalcemia. Normal serum calcium is 9 to 11 mg/dl.
The nurse is caring for a bedridden client admitted with multiple myeloma and a serum calcium level of 13 mg/dl. Which of the following is the most appropriate nursing action?
Show answer and rationale
Correct answer: D. Provide passive range-of-motion exercises and encourage fluid intake
A client who has a serum calcium of 13 mg/dl has hypercalcemia. Normal serum calcium is 9 to 11 mg/dl. Fluid intake promotes renal excretion of excess calcium. ROM exercises promote reabsorption of calcium into bone. Placing a tracheostomy at the bedside is a nursing intervention for hypocalcemia. Although calcium gluconate may be administered in hypocalcemia, it is never administered IM.
An older adult client admitted with heart failure and a sodium level of 113 mEq/L is behaving aggressively toward staff and does not recognize family members. When the family expresses concern about the client’s behavior, the nurse would respond most appropriately by stating which of the following?
Show answer and rationale
Correct answer: A. "The sodium level is low, and the confusion will resolve as the levels normalize."
Normal serum level is 135 to 145 mEq/L. Neurological symptoms occur when sodium levels fall below 120 mEq/L. The confusion is an acute condition that will go away as the sodium levels normalize. Dementia is an irreversible condition.
A client with a serum sodium of 115 mEq/L has been receiving 3% NS at 50 ml/hr for 16 hours. This morning the client feels tired and short of breath. Which of the following interventions is a priority?
Show answer and rationale
Correct answer: C. Assess for signs of fluid overload
A complication of hypertonic sodium solution administration is fluid overload. Although turning down the infusion, checking the latest sodium level, and notifying the physician may all be reasonable, the priority intervention is to assess for manifestations of fluid overload. Assessment is always the priority to determine what action to take next.
A client with chronic renal failure receiving dialysis complains of frequent constipation. When performing discharge teaching, which over-the-counter products should the nurse instruct the client to avoid at home?
Show answer and rationale
Correct answer: B. Milk of magnesia
Milk of magnesia contains magnesium, an electrolyte that is excreted by kidneys. Clients with renal failure are at risk for hypermagnesemia, as their bodies cannot excrete the excess magnesium. The client should avoid magnesium-containing laxatives.
A client is receiving intravenous potassium supplementation in addition to maintenance fluids. The urine output has been 120 ml every 8 hours for the past 16 hours and the next dose is due. Before administering the next potassium dose, which of the following is the priority nursing action?
Show answer and rationale
Correct answer: B. Notify the physician of the urine output and hold the dose
Urine output is an indication of renal function. Normal urine output is at least 30 ml/hour. Clients with impaired renal function are at risk for hyperkalemia. Initiating a lab draw requires a physician order.
The nurse should monitor for clinical manifestations of hypophosphatemia in which of the following clients?
Show answer and rationale
Correct answer: B. A client who is alcoholic receiving total parenteral nutrition
A client with osteoporosis taking vitamin and calcium supplements, a client with chronic renal failure awaiting dialysis, and a client with hypoparathyroidism secondary to thyroid surgery are at risk for hyperphosphatemia. Alcoholics and clients receiving total parenteral nutrition (TPN) are at risk for low phosphorus levels, due to poor intestinal absorption and shifting of phosphorus into cells along with insulin and glucose.
A client with pancreatitis has been receiving potassium supplementation for 4 days since being admitted with a serum potassium of 3.0 mEq/L. Today the potassium level is 3.1 mEq/L. Which of the following laboratory values should the nurse check before notifying the physician of the client’s failure to respond to treatment?
Show answer and rationale
Correct answer: D. Magnesium
Low serum magnesium levels can inhibit potassium ions from crossing cell membranes, resulting in potassium loss through the urine. Generally, low magnesium levels must be corrected before potassium replacement is effective.
The nurse should include which of the following instructions to assist in controlling phosphorus levels for a client in renal failure?
Show answer and rationale
Correct answer: A. Take aluminum-based antacids such as aluminum hydroxide (Amphojel) with or after meals
Aluminum-based antacids are often prescribed in the treatment of renal failure to bind with phosphate and increase elimination through the GI tract. Dairy products and nuts are foods high in phosphorus. Chocolate, meats, and whole grains are foods high in magnesium. Clients with renal failure often require calcium supplements as a result of poor vitamin D metabolism and in order to prevent hyperphosphatemia.
A client with pneumonia presents with the following arterial blood gases: pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45. Which of the following is the most appropriate nursing intervention?
Show answer and rationale
Correct answer: D. Place client in high-Fowler’s position
The client with a pH of 7.28, PaCO2 of 74, HCO3 of 28 mEq/L, and PO2 of 45 is in a state of respiratory acidosis. Placing the client in high Fowler’s position will facilitate the expansion of the lungs and help the client blow off the excess CO2. Sedatives would impede respirations. The question does not indicate which is the affected lung, so left lateral position would not be a first choice. Breathing into a paper bag will cause the PCO2 to rise higher.
A client with COPD feels short of breath after walking to the bathroom on 2 liters of oxygen nasal cannula. The morning’s ABGs were pH of 7.36, PaCO2 of 62, HCO3 of 35 mEq/L, O2 at 88% on 2 liters. Which of the following should be the nurse’s first intervention?
Show answer and rationale
Correct answer: D. Encourage the client to rest and to use pursed-lip breathing technique
Clients with COPD, especially those who are in a chronic compensated respiratory acidosis, are very sensitive to changes in O2 flow, because hypoxemia rather than high CO2 levels stimulates respirations. Deep breaths are not helpful, because clients with COPD have difficulty with air trapping in alveoli. There is no need to call the physician, since this client is presently most likely at baseline.
A client who had a recent surgery has been vomiting and becomes dizzy while standing up to go to the bathroom. After assisting the client back to bed, the nurse notes that the blood pressure is 55/30 and the pulse is 140. The nurse hangs which of the following IV fluids to correct this condition?
Show answer and rationale
Correct answer: B. 0.9 NS at an open rate
A client who recently had surgery is vomiting, becomes dizzy when standing up, has a blood pressure of 55/30, and has a pulse of 140 is hypovolemic and requires plasma volume expansion. Isotonic fluids such as 0.9 NS will expand volume. Hypotonic fluids such as 0.45 NS will leave the intravascular space. D5W will metabolize into free water and leave the intravascular space. D5.45 NS is a good maintenance fluid but a rate of 50 ml per hour is not sufficient to expand the vascular volume quickly.
A client with renal failure enters the emergency room after skipping three dialysis treatments to visit family out of town. Which set of ABGs would indicate to the nurse that the client is in a state of metabolic acidosis?
Show answer and rationale
Correct answer: A. pH of 7.33, PCO2 of 35, HCO3 of 17
A pH of 7.33, PCO2 of 35, and HCO3 of 17 and a pH of 7.25, PCO2 of 56, and HCO3 of 28 both indicate acidosis. The pH of 7.25 is a respiratory acidosis. A pH of 7.41, PCO2 of 49, and HCO3 of 30 is a compensated metabolic alkalosis. A pH of 7.43, PCO2 of 36, and HCO3 of 26 is normal.
A client with a small bowel obstruction has had an NG tube connected to low intermittent suction for 2 days. The nurse should monitor for clinical manifestations of which acid-base disorder?
Show answer and rationale
Correct answer: B. Metabolic alkalosis
Clients with gastric suctioning can lose hydrogen ions, resulting in a metabolic alkalosis.
Which of the following assessment findings would indicate to the nurse that a client’s diabetic ketoacidosis is deteriorating?
Show answer and rationale
Correct answer: D. Deep tendon reflexes decreasing from 12 to 11
A decrease in deep tendon reflexes is a sign that pH is dropping and that metabolic acidosis is worsening in diabetic ketoacidosis. An increase in bicarbonate would indicate that the acidosis is being corrected. A urine pH less than 6 indicates the kidneys are excreting acid. Serum potassium levels are expected to fall because acidosis is corrected and potassium moves back into the intracellular space.
A client who is admitted with malnutrition and anorexia secondary to chemotherapy is also exhibiting generalized edema. The client asks the nurse for an explanation for the edema. Which of the following is the most appropriate response by the nurse?
Show answer and rationale
Correct answer: D. "Poor nutrition has caused decreased blood protein levels, and fluid has moved from the blood vessels into the tissues."
Generalized edema, or anasarca, is often seen in clients with low albumin levels secondary topoor nutrition. Decreased oncotic pressure within the blood vessels allows fluid to move from the intravascular space to the interstitial space.
A client with a recent thyroidectomy complains of numbness and tingling around the mouth. Which of the following findings indicates the serum calcium is low?
Show answer and rationale
Correct answer: C. Positive Chvostek’s sign
Numbness and tingling around the mouth indicate hypocalcemia, which results in neuromuscular irritability. A positive Chvostek’s sign is the contraction of facial muscles when the facial nerve in front of the ear is tapped. Bone pain, nausea, and depressed deep tendon reflexes are signs of hypercalcemia.
A client recently diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) complains of headache, weight gain, and nausea. Which of the following is an appropriate nursing diagnosis for this client?
Show answer and rationale
Correct answer: C. Excess fluid volume related to increased water retention
The client exhibits signs of excess fluid volume. Syndrome of inappropriate antidiuretic hormone (SIADH) is the release of excess ADH by the pituitary gland, which results in hypervolemic hyponatremia and clinical manifestations of headache, weight gain, and nausea.
The registered nurse is delegating nursing tasks for the day. Which of the following tasks may the nurse delegate to a licensed practical nurse?
Show answer and rationale
Correct answer: A. Obtain a glucose level on a client admitted with diabetes mellitus
A licensed practical nurse may obtain a fingerstick glucose on a client with diabetes mellitus. A licensed practical nurse may not assess a client for metabolic acidosis, evaluate blood gases on a client with respiratory alkalosis, or perform a neurological assessment on a client suspected of hypocalcemia.
A client who is post-gallbladder surgery has a nasogastric tube, decreased reflexes, pulse of 110 weak and irregular, and blood pressure of 80/50 and is weak, mildly confused, and has a serum of potassium of 3.0 mEq/L. Based on the assessment data, which of the following is the priority intervention?
Show answer and rationale
Correct answer: D. Notify the physician
The priority intervention for a client who had gallbladder surgery and has a nasogastric tube, decreased reflexes, pulse of 110 weak and irregular, and blood pressure of 80/50 and is weak, mildly confused, and has a serum potassium of 3.0 mEq/L would be to notify the physician that the potassium level is low. After notifying the physician, the furosemide (Lasix) may be withheld and potassium supplement should be administered as prescribed and may even be increased after talking with the physician. The client may also be instructed on foods high in potassium. These are all appropriate interventions but not the priority.
The nurse is admitting a client with a potassium level of 6.0 mEq/L. The nurse reports this finding as a result of
Show answer and rationale
Correct answer: A. malabsorption syndrome.
A serum potassium level of 6.0 mEq/L is indicative of acute renal failure. Malabsorption syndrome, nasogastric drainage, and laxative abuse may result in a low serum potassium level, because output may be greater than input. Diarrhea results in malabsorption syndrome and can come from laxative abuse. Fluids and electrolytes may be lost in the nasogastric drainage. Normal serum potassium is 3.5 to 5.5 mEq/L.
The nurse assesses a client to be experiencing muscle cramps, numbness, and tingling of the extremities, and twitching of the facial muscle and eyelid when the facial nerve is tapped. The nurse reports this assessment as consistent with which of the following?
Show answer and rationale
Correct answer: C. Hypocalcemia
Normal serum calcium is 9 to 11 mg/dl. A client who has hypocalcemia would experience muscle cramps, numbness, and twitching of the facial muscles and eyelid when the facial nerve is tapped. Hypocalcemia may result from renal failure, hypoparathyroidism, acute pancreatitis, liver disease, malabsorption syndrome, and vitamin D deficiency. Normal serum potassium level is 3.5 to 5.5 mEq/L. Normal serum sodium is 135 to 145 mEq/L. Normal serum magnesium is 1.5 to 2.5 mEq/L.
Which of the following should the nurse include when preparing to teach a class on the regulation and functions of electrolytes?
Show answer and rationale
Correct answer: C. Chloride is lost in hydrochloride acid
Sodium is essential to maintain extracellular fluid water balance. Phosphate is the major anion in intracellular fluid water balance that is essential in the function of muscle, red blood cells, and nervous system. A person tends to excrete more calcium with age. Chloride is lost through hydrochloride acid.
The nurse evaluates which of the following clients to have hypermagnesemia?
Show answer and rationale
Correct answer: D. A client who has renal failure, takes antacids, and has a magnesium level of 2.9 mEq/L
Normal serum magnesium is 1.5 to 2.5 mEq/L. Clients who have chronic alcoholism and hyperthyroidism are prone to hypomagnesemia. A client who has congestive heart failure, takes a diuretic, and has a magnesium level of 2.3 mEq/L falls within the normal magnesium range.
The nurse is evaluating the serum laboratory results on the following four clients. Which of the following laboratory results is a priority for the nurse to report first?
Show answer and rationale
Correct answer: A. A client with dehydration and a sodium level of 149 mEq/L
Although a client with acute osteoporosis may have a high serum calcium, a level of 10.6 mg/ dl is normal. Normal serum calcium is 9 to 11 mg/dl. Normal serum magnesium is 1.5 to 2.5 mEq/L. A client who has renal failure is prone to hypermagnesemia, but a level of 2.5 mEq/L is at the upper limit of normal. A client who has bulimia generally vomits enough to result in a low potassium level, but a potassium level of 3.6 mEq/L is low-normal. Normal serum potassium is 3.5 to 5.5 mEq/L. Normal serum sodium is 135 to 145 mEq/L. The sodium level generally goes up with dehydration. A sodium level of 149 mEq/L is elevated.
The registered nurse is delegating client assignments to unlicensed assistive personnel. Which of the following clients does not require additional monitoring and assessment and may be delegated to unlicensed assistive personnel?
Show answer and rationale
Correct answer: D. A client who has been experiencing diarrhea and has a serum chloride level of 100 mEq/L
Normal serum chloride is 95 to 105 mEq/L. A client with diarrhea may experience a low chloride level, but 100 mEq/L is within the normal range and may be delegated to unlicensed assistive personnel. Normal serum magnesium is 1.5 to 2.5 mEq/L. A magnesium level of 3.0 mEq/L is elevated and may occur in renal failure. Phosphate levels may be elevated with healing fractures. A phosphate level of 5.0 mg/dl is elevated. Normal serum phosphate is 2.8 to 4.5 mg/dl. A sodium level of 128 mEq/L is decreased and may be found with dehydration. Normal serum sodium is 135 to 145 mEq/L.
What to do with your score
Score the set, then spend longer on the review than you did on the questions. For every item you missed, decide which of three things went wrong: you did not know the fact, you misread what the item was asking, or you knew the fact and still chose second-best. Those need three different fixes — content review, slower reading, and priority-framework practice — and lumping them together is why question banks stop working for people.
Read the rationale on the items you got right as well. Arriving at the correct option for the wrong reason is common, and it does not survive a harder version of the same question.
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