NCLEX Core Content Questions & Answers with Rationale

NCLEX Core Content Questions & Answers with Rationale Fluids and Electrolytes 1. The nurse is caring for a client with fluid volume overload. What is the best position for this client? A. tripod B. flat supine C. reverse trendelenburg D. head of bed elevated Rationale D. Yes! Help that fluid move away from the heart and lungs when you sit people up cardiac output goes up – breathing is better too! B. Killer answer!!! This is used for Fluid Volume Deficit – hypotension etc. C. Tilt test…now how are you going to accomplish this? And if you did, they would develop exaggerated ankle edema. A. This one is used for hypoxia and breathing difficulties. 2. The nurse is caring for a client with decreased cardiac output secondary to heart failure with fluid volume overload. The effects of diminished renal perfusion will have which physiologic response? A. diuresis B. increased fluid retention C. elevated bicarbonate level D. paroxysmal idiopathic narcosis Rationale B. Yes when the cardiac output decreases renal perfusion decreases which leads to decreased urine output and fluid retention A. No! that’s what we want, but there is not enough blood to the kidney and the renin- angiotension-aldosterone mechanism in activated C. Doesn’t match! D. Sudden onset/ of unknown cause/ unconsciousness? Don’t pick things that you don’t know what they mean! 3. The nurse is providing post-operative care to a craniotomy client. Diabetes insipidus is suspected when the client’s urine output suddenly increases significantly. Which action takes highest priority? A. Continue to monitor urine output B. Check a pulse C. Check a blood pressure D. Check level of consciousness (LOC) Rationale: C. This is the best answer because we are “worried” this client is going into SHOCK. So…..you better be checking a BP. This is a time where checking the BP is appropriate. (If we “assume the worst” I better check a blood pressure. It could have dropped out the bottom.) A. Continuing to monitor U/O is important but I need to find out if they are already shocky. B. Checking the pulse is a good thing, but, not as important as checking the BP. D. If my client is going into shock the highest priority is to assess the BP. 4. The nurse is caring for a client with polyuria. A water conservation test is ordered. What diagnosis is being ruled out? A. psychogenic polydipsia B. diabetes mellitus C. renal failure D. hyperpituitarism Rationale: A. Remember the psychiatric client that drank so much water and urinated so much? Well what happens when they can’t have water? Do they still have excess urination? B. polyuria associated with DM is tested by blood glucose C. What does this have to do with restricting their water intake? RF . creatinine D. That would be too much pituitary hormones – polyuria from DI is not enough ADH 5. The nurse is called to a client’s room for shortness of breath. Which of the following are causes of shortness of breath? (pick all that apply) A. hypoxemia B. anemia C. decreased cardiac output D. retained toxins E. fluid overload F. pain G. ascites Rationale: A. hypoxemia – YES obviously B. anemia - YES – not enough oxygen carrying capacity C. decreased cardiac output – YES – not enough oxygen to tissues D. retained toxins – NO E. fluid overload – YES – will lead to pulmonary edema and hypoxia F. pain - NO G. ascites – YES – puts pressure on the diaphragm not letting them breathe effectively 6. Which of the following clients is at risk for hypomagnesemia? A. Client with a history of heart disease B. Client taking Magnesium based antacids C. Client with a parathyroid disorder D. Client admitted with alcohol abuse Rationale: D. is the answer because alcoholics don’t eat and instead drink alcohol. 7. The nurse has just gotten out of report and has the following patients. Which client would she see first? A. hyponatremia B. hyperthermia C. hypermagnesemia D. hypomagnesemia Rationale: C. Yes – they may be hypoventilating A. Sodium has to go very low before they seize B. Fever D. not as dangerous as hypomagnesaemia 8. The nurse is caring for a client with hyperparathyroidism. The nurse will monitor the client for which of the below complications? (choose all that apply) A. kidney stones B. diarrhea C. osteoporosis D. tetany E. fluid volume deficit Rationale: A. Yes because too much calcium in blood = too much calcium in urine and increased risk of kidney stones B. No – hypercalcemia leads to constipation not diarrhea C. Yes because the PTH is pulling the calcium from the bones leaving them weak D. No this is related to hypocalcemia E. Does not apply 9. You are providing care to a post-operative parathyroidectomy client. Which of the following takes highest priority? A. psychoses B. renal calculi C. positive trousseaus D. laryngospasm Rationale: D. yes! Airway! Most important…don’t pick airway just because it sounds scary all by itself, but, if it is applicable pick it. B. They can cause problems and lead to pain and possibly renal failure – but not as fast as airway obstruction C. Oh no, you have a positive trousseau’s – so the arm curls when you put a blood pressure cuff on it~ D. Disturbing, and important – but AIRWAY wins! 10. The nurse is caring for a client that is scheduled to receive Lasix® 40 mg IVP BID as well as 20 meq of Kdur® BID. The patients morning lab work reveals potassium level is 2.7 this morning. How should the nurse proceed? A. notify the physician of the K level immediately B. administer the medications as scheduled and notify the physician on rounds C. give the potassium, but hold the lasix until doctor rounds D. assess the client for signs of hypokalemia Rationale: A. Yes! This is a very low level B. No – K is dangerously low – doctors don’t make predictable rounds C. This is delaying care and confuses the issue of how much K needs to be administered now D. Delays care – what if there are no symptoms? Will you wait for symptoms to treat? Bonus! The nurse is caring f