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EDAPT: Introduction to NCLEX Readiness Questions and Answers Latest Update

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EDAPT: Introduction to NCLEX Readiness
Questions and Answers Latest Update

The nurse is caring for a client with a phosphate level of 6.2 mg/dL
(reference range: 3 - 4.5 mg/dL). For each finding, click to specify if the
assessment finding is anticipated or not anticipated. Ans: Anticipated:

Hypotension

Diminished peripheral pulses

Positive Chvostek's sign

Prolonged cardiac QT interval

Not Anticipated:

Absent deep tendon reflexes

Hypoactive bowel sounds

Serum calcium level 10 mg/dL

The nurse is caring for a client with telemetry monitoring and observes an
electrocardiogram (ECG) rhythm that shows:

one P wave for every QRS interval

PR interval 0.16 seconds

QRS complex 0.06 seconds


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heart rate 64 beats per minute

Which action should the nurse take? Ans: Document the findings.

The nurse is providing dietary education to a pregnant client with
phenylketonuria (PKU). Which foods, if appearing on the client's lunch tray,
would indicate a need for further teaching? Select all that apply. Ans: Dairy

Eggs

Legumes

Meat

Nuts

The nurse is caring for a client diagnosed with diabetes mellitus type 1. The
client reports feeling irritable and anxious with diaphoresis and tremors.
After serving the client a glass of milk, the nurse should next __________.
Ans: Check serum glucose

The nurse is caring for a client in Stage 1 of labor and analyzing the fetal
heart rate pattern. Match the fetal heart rate deceleration to the
corresponding cause and initial action. Ans: Early deceleration:

Cause: Fetal head compression

Initial Action: Continue to monitor

Variable deceleration:

Cause: Umbilical cord compression

Initial Action: Position change

Late declaration:


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