NUR 165 NCLEX 1 (NUR 165. Reference: Iggy &
Powerpoints) Questions With Complete Solutions
9. 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?
A. Provide passive ROM exercises and encourage fluid intake
B. Teach the client to increase intake of whole grains and nuts
C. Place a tracheostomy tray at the bedside
D. Administer calcium gluconate IM as ordered
A. Provide passive ROM exercises and encourage fluid intake
Explanation
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.
11. 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?
A. Turn down the infusion
B. Check the latest sodium level
,C. Assess for signs of fluid overload
D. Place a call to the physician
C Assess for signs of fluid overload
Assessment should be done first
18. 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?
A. Administer a sedative
B. Place client in left lateral position
C. Place client in high-Fowler's position
D. Assist the client to breathe into a paper bag
C. Place client in high-Fowler's position
19. 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?
A. Call the physician and report the change in client's condition
B. Turn the client's O2 up to 4 liters nasal cannula
C. Encourage the client to sit down and to take deep breaths
D. Encourage the client to rest and to use pursed-lip breathing
technique
... D. Encourage the client to rest and to use pursed-lip breathing
technique
,Explanation
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.
24. Which of the following assessment findings would indicate
to the nurse that a client's diabetic ketoacidosis is deteriorating?
A. Deep tendon reflexes decreasing from +2 to +1
B. Bicarbonate rising from 20 mEq/L to 22 mEq/L
C. Urine pH less than 6
D. Serum potassium decreasing from 6.0 mEq/L to 4.5 mEq/L
...A. Deep tendon reflexes decreasing from +2 to +1
Explanation
A decrease in deep tendon reflexes is a sign that pH is dropping
and that metabolic acidosis is worsening to 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.
, 29. 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?
A. Withhold furosemide (Lasix)
B. Notify the physician
C. Administer the prescribed potassium supplement
D. Instruct the client on foods high in potassium
... B. Notify the physician
Explanation
The priority intervention for a client who had 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 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.
42. The client is admitted with a serum sodium level of 110
mEq/L. Which nursing intervention should be implemented?
A. Encourage fluids orally.
B. Administer 10% saline solution IVPB.
Powerpoints) Questions With Complete Solutions
9. 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?
A. Provide passive ROM exercises and encourage fluid intake
B. Teach the client to increase intake of whole grains and nuts
C. Place a tracheostomy tray at the bedside
D. Administer calcium gluconate IM as ordered
A. Provide passive ROM exercises and encourage fluid intake
Explanation
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.
11. 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?
A. Turn down the infusion
B. Check the latest sodium level
,C. Assess for signs of fluid overload
D. Place a call to the physician
C Assess for signs of fluid overload
Assessment should be done first
18. 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?
A. Administer a sedative
B. Place client in left lateral position
C. Place client in high-Fowler's position
D. Assist the client to breathe into a paper bag
C. Place client in high-Fowler's position
19. 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?
A. Call the physician and report the change in client's condition
B. Turn the client's O2 up to 4 liters nasal cannula
C. Encourage the client to sit down and to take deep breaths
D. Encourage the client to rest and to use pursed-lip breathing
technique
... D. Encourage the client to rest and to use pursed-lip breathing
technique
,Explanation
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.
24. Which of the following assessment findings would indicate
to the nurse that a client's diabetic ketoacidosis is deteriorating?
A. Deep tendon reflexes decreasing from +2 to +1
B. Bicarbonate rising from 20 mEq/L to 22 mEq/L
C. Urine pH less than 6
D. Serum potassium decreasing from 6.0 mEq/L to 4.5 mEq/L
...A. Deep tendon reflexes decreasing from +2 to +1
Explanation
A decrease in deep tendon reflexes is a sign that pH is dropping
and that metabolic acidosis is worsening to 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.
, 29. 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?
A. Withhold furosemide (Lasix)
B. Notify the physician
C. Administer the prescribed potassium supplement
D. Instruct the client on foods high in potassium
... B. Notify the physician
Explanation
The priority intervention for a client who had 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 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.
42. The client is admitted with a serum sodium level of 110
mEq/L. Which nursing intervention should be implemented?
A. Encourage fluids orally.
B. Administer 10% saline solution IVPB.
