Comprehensive Review for the NCLEX-PN® Exam
Fundamentals core Questions and Correct Answers |
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The nurse who is assisting in a weight loss program prepares to monitor
a client's weight. The client receives education about caloric intake and
weight reduction. In order to lose 2 pounds per week the caloric intake
should be decreased by how many calories per day?
Ans: 1000 calories
Assignment Expert
Rationale:
The amount of weight loss in a client in a weight loss program is based
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on food intake, energy expenditure, and fluid loss. To obtain a weight
loss of 1 pound per week the client needs a decrease in daily caloric
intake of 500 calories. To lose 2 pounds per week the client needs to
decrease intake by 1000 calories per day.
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Client Needs: Physiological IntegrityClinical Judgment/Cognitive Skills:
Generate SolutionsLevel of Cognitive Ability: ApplyingContent Area:
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Foundations of Care: Therapeutic DietsIntegrated Process: Nursing
Process/PlanningPriority Concepts: Nutrition, Clinical
JudgmentStrategy(ies): Subject
Rationale Strategy
The nurse is assisting to admit a client with a diagnosis of acute Guillain-
Barré syndrome. The nurse knows that if the disease progresses to a
severe level, the client will be at risk for which acid-base imbalance?
Ans: Respiratory Acidosis
Rationale:
Guillain-Barré is a neuromuscular disorder in which the client may
experience weakening or paralysis of the muscles used for respiration.
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This could cause the client to retain carbon dioxide, which leads to
respiratory acidosis resulting from progressive respiratory insufficiency
as the paralysis ensues.
Client Needs: Physiological IntegrityClinical Judgment/Cognitive Skills:
Analyze CuesLevel of Cognitive Ability: AnalyzingContent Area:
Foundations of Care: Acid-BaseHealth Problem: Adult Health:
Neurological: Guillain-Barré SyndromeIntegrated Process: Nursing
Process/Data CollectionPriority Concepts: Gas Exchange, Acid-Base
BalanceStrategy(ies): Subject
Assignment Expert
The nurse is caring for a client with a health care associated infection
caused by methicillin-resistant Staphylococcus aureus. Contact
precautions are prescribed for the client. The nurse prepares to irrigate
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the wound and apply a new dressing. Which protective interventions
would the nurse use to perform this procedure? Select all that apply.
Ans: Put on mask
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don gown and gloves
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wear a pair of protective goggles
Rationale:
Contact precautions are in place, which include wearing gloves and a
gown while providing care to the client. The mask and goggles are
indicated because of the potential of splash contact during the wound
irrigation procedure. Goggles are worn to protect the mucous membranes
of the eye during interventions that may produce splashes of blood, body
fluids, secretions, and excretions. Shoe protectors are not necessary and
are used in operating rooms in the surgical departments. If the client is
under airborne or droplet precautions, a mask is worn by the client when
going outside of the room. Goggles are not worn by clients.
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Client Needs: Safe and Effective Care EnvironmentClinical
Judgment/Cognitive Skills: Take ActionLevel of Cognitive Ability:
ApplyingContent Area: Foundations of Care: Infection ControlHealth
Problem: Adult Health: Integumentary:
Inflammations/InfectionsIntegrated Process: Nursing
Process/ImplementationPriority Concepts: Infection, SafetyStrategy(ies):
Subject
A licensed practical nurse (LPN) is providing follow-up teaching after a
client underwent an upper gastrointestinal (GI) series with diatrizoate
used for contrast. The nurse instructs the client that which may occur
Assignment Expert
from the diatrizoate?
Ans: Diarrhea
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Rationale: If diatrizoate is used for contrast, significant diarrhea is
possible. It may also cause nausea and vomiting. Excessive flatus,
abdominal pain, and gastrointestinal bleeding are not associated with
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diatrizoate administration.
Client Needs: Physiological IntegrityClinical Judgment/Cognitive Skills:
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Take ActionLevel of Cognitive Ability: ApplyingContent Area:
Foundations of Care: Diagnostic TestsIntegrated Process: Nursing
Process/ImplementationPriority Concepts: Patient Education,
EliminationStrategy(ies): Subject
The nurse is assigned to assist in caring for a client who has had surgery
and has pneumatic sequential compression devices (SCDs) in place. The
client asks about these devices. The nurse instructs the client that SCDs
are used for which purpose?
Ans: Promoting venous return to the heart
Rationale: Pneumatic sequential compression devices (SCDs) are placed
on the client's lower extremities during and after surgery to prevent
venous thrombotic embolic complications. The SCDs promote venous