NCLEX questions for MidTerm Exam 2 2022 with complete solution

A patient is brought to the emergency department in a comatose state after developing hyperosmolar hyperglycemic non-ketotic syndrome (HHNS). The nurse begins her care and assessment of this patient. What is the nurse's first priority in this situation? a)Providing isotonic fluid replacement b) Maintaining the patients cervical spine c) Administering insulin IM d) Monitoring serum chloride levels Correct answer- a)Providing isotonic fluid replacement In the intensive care unit, the nurse cares for a client who has been admitted with diabetic ketoacidosis. The client is on a continuous infusion of regular insulin at 5 units/hr via IV pump. Which actions should the nurse expect to implement? Select all that apply. 1. Administer potassium supplement when serum potassium is 3.5-5.0 mEq/L (3.5-5.0 mmoi/L) 2. Discontinue insulin infusion when fingerstick blood glucose is <350 mg/dl 3. Increase the insulin infusion rate when blood glucose level decreases 4. Monitor fingerstick or serum blood glucose every hour 5. Start infusion of dextrose 5% water when blood glucose is <250 mg/dl (13.9 mmoi/L) Correct answer- 1, 4, 5 Insulin shifts the potassium back into the intracellular space. As a result, serum potassium levels will then begin to decrease once insulin is started. This client is on a continuous insulin drip so serum potassium will continue to decrease. When serum potassium is normal, a potassium supplement (usually in the form of an IV piggyback) should be added to the medication regimen to prevent impending hypokalemia (K+ <3.5 mEq/L [3.5 mmoi/L]) (Option 1). Low potassium (hypokalemia) can cause muscle weakness, cramps, fatigue, and life-threatening cardiac arrhythmias. When the client is on an insulin drip, a fingerstick or serum blood glucose level should be checked at least hourly (Option 4). D5W is added to the IV fluid when blood glucose is <250 mg/dl (13.9 mmoi/L) to prevent a hypoglycemic reaction with regular (short-acting) IV insulin (Option 5). Insulin and D5W should be continued until the acidosis resolves. The insulin infusion is titrated down as blood glucose is lowered (Option 3); it is discontinued when the client is switched to subcutaneous injections. This generally occurs when blood glucose is <200 mg/dl (11.1 mmoi/L) and there is no evidence of metabolic acidosis (Option 2). The nurse cares for a client diagnosed with type I diabetes mellitus who came to the emergency department with the acute complication of diabetic ketoacidosis (DKA). After checking the blood glucose, which prescription should the nurse implement first? 1. Insert an indwelling urinary catheter for accurate output calculation 2. Obtain serum potassium level results and report to the primary health care provider 3. Prepare an insulin drip for intravenous (IV) infusion as prescribed 4. Start an IV line and infuse normal saline as prescribed Correct answer- 1 The priority intervention in DKA is to start an IV infusion for bolus rehydration therapy with normal saline. This should occur before insulin infusion as insulin will result in water, potassium, and glucose entering the cells, worsening the dehydration and electrolyte imbalances. A client with type I diabetes mellitus is brought to the emergency department by his wife. The client has fruity breath with rapid, deep respirations at 36 breaths per minute, reports abdominal pain, and appears weak. The nurse should anticipate implementation of which prescription(s)? Select all that apply. 1. Administer dextrose 50 mg intravenous (IV) push 2. Instruct client to breathe into a paper bag to treat hyperventilation 3. Perform a fingerstick and serum blood glucose test 4. Prepare to administer an IV infusion of regular insulin 5. Start an IV line and administer a bolus of normal saline Correct answer- 3, 4, 5 The client is exhibiting the cardinal signs and symptoms of diabetic ketoacidosis (DKA). DKA is an acute life-threatening complication, typically of type I diabetes, characterized by hyperglycemia, ketosis, and acidosis. It is caused by an intense deficit of insulin. Because some of the symptoms of hypoglycemia and DKA overlap, a blood glucose level should be checked to ensure that hyperglycemia is present.Option 1 would make the situation worse, and option 2 is inappropriate as the client is acidotic and needs to blow off the acid. A client is diagnosed with diabetic ketoacidosis (DKA). The client reports frequent urination, thirst, and weakness. The nurse assesses a temperature of 102.4 F (39.1 C), fruity breath, deep labored respirations with a rate of 30/min, and dry mucous membranes. What is the priority nursing diagnosis (ND) at this time? 1. Deficient fluid volume related to osmotic diuresis 2. Imbalanced nutrition, less than body requirements related to inability to metabolize glucose 3. Ineffective breathing pattern related to the presence of metabolic acidosis 4. Ineffective health maintenance related to the inability to manage DM during illness Correct answer- Option 1 Deficient fluid volume related to osmotic diuresis secondary to hyperglycemia as evidenced by dry mucous membranes and client report of frequent urination, thirst, and weakness is the priority ND. Hyperglycemia leads to osmotic diuresis, dehydration, electrolyte imbalance, and possible hypovolemic shock and renal failure. Therefore, this condition requires rapid correction through the infusion of isotonic intravenous fluids and poses the greatest risk to the client's survival (Option 1 ). The nurse is caring for an adolescent client diagnosed with type 1 diabetes. The client exhibits hot, dry skin and a glucose level of 350 mg/dL (19.4 mmoi/L). Arterial blood gases show a pH of 7.27. STAT serum chemistry labs have been drawn. Cardiac monitoring shows a sinus rhythm with peaked T waves, and the client has minimal urine output. What is the nurse's next priority action? 1 . Administer IV regular insulin 2. Administer normal saline infusion 3. Obtain urine for urinalysis c 4. Request prescription for potassium infusion Correct answer- Option 2 Potassium should never be given until the serum potassium level is known to be normal or low and urinary voiding is observed. Peaked T waves indicate hyperkalemia in this client. Clients with insulin deficiency frequently have increased serum potassium levels due to the extracellular shift despite having total body potassium deficit from urinary losses. Once insulin is given, serum potassium levels drop rapidly, often requiring potassium replacement. Potassium is never given as a rapid IV bolus, as cardiac arrest may result. Educational objective: Clients with diabetic ketoacidosis and hyperosmolar hyperglycemic state require IV normal saline as a priority due to severe dehydration. Once fluids are given as a bolus, insulin is initiated. The serum potassium levels can be elevated in the initial stages despite a low total body potassium. Potassium repletion is started once the serum potassium levels are normalized or trending low (from elevated levels). A nurse is caring for 4 clients. Which prescription by the health care provider would the nurse question and seek further clarification before administering? 1. 0.45% sodium chloride solution for a client with severe gastroenteritis who had 12 episodes of diarrhea and vomiting in the past 4 hours 2. IV bolus of 1000 ml 0.9% sodium chloride solution for a client in anaphylaxis due to a food allergy 3. IV bolus of 1000 ml 0.9% sodium chloride solution for a client with diabetic ketoacidosis who has a serum glucose level of 650 mg/dl (36.1 mmoi/L) 4. IV mannitol 25°/o solution for a client with a closed head injury who is exhibiting signs of increased intracranial pressure Correct answer- Option 1 The nurse should question the administration of a hypotonic IV solution (ie, 0.45o/o sodium chloride) to replace gastrointestinal tract fluid losses as this would create a concentration gradient and shift fluid out of the intravascular compartment into the interstitial tissue and cells, worsening the client's fluid volume deficit. Isotonic IV solutions (eg, 0.9% sodium chloride, lactated Ringer's) have the same osmolality as plasma and are administered to expand intravascular fluid volume. These solutions replace fluid losses commonly associated with vomiting and diarrhea, burns, and traumatic injury. (Option 2) Anaphylaxis causes increased capillary permeability, leaking intravascular fluid into free spaces; this places the client at risk for hypotension. Therefore, isotonic solutions should be given to such clients. (Option 3) Extreme hyperglycemia in a client with diabetic ketoacidosis results in osmotic diuresis and dehydration. The immediate initial treatment is IV fluid resuscitation with isotonic 0.9o/o sodium chloride to replace fluid losses, stabilize vital signs, reestablish urine output, and dilute the serum glucose concentration before initiating insulin therapy. (Option 4) A client with head trauma is at risk for increased intracranial pressure due to inflammation and cerebral edema. IV mannitol is an osmotic diuretic that reduces cerebral edema by pulling water from the cerebral cells into the vasculature. The nurse is making assignments for the next shift. Which client should the nurse assign to the new nurse coming out of orientation? 1. Client diagnosed with chronic anemia receiving iron via IV route [53%] 2. Client newly admitted for uncontrolled diabetes mellitus type 2 with blood glucose >600 mg/dl (33.3 mmoi/L) [3o/o] 3. Client undergoing ultrafiltration for congestive heart failure [3°/o] .4. Client with a prescription for routine hemodialysis who has chronic renal failure [40o/o] Correct answer- Option 4: Explanation: The nurse is looking for the most stable client to assign to the new nurse. The client who is scheduled for hemodialysis has a chronic disorder and receives this therapy on a regular basis. There is no indication that this client might be unstable. (Option 1) There is a high incidence of IV iron causing hypersensitivity reactions, including anaphylaxis. Therefore, a test dose needs to be given first. This client should be assigned to a more experienced nurse. (Option 2) The client with hyperglycemia is at high risk for diabetic ketoacidosis or hyperglycemic hyperosmolar non ketotic coma. Both are associated with acute and chronic complications and require careful assessment and prompt nursing intervention. This client should also be assigned to a more experienced nurse. (Option 3) Ultrafiltration (removal of excess fluid) is a complex task that requires extra training to perform. It is performed for clients who are not responding to IV diuretics. In addition, clients receiving ultrafiltration are more likely to be hemodynamically unstable due to their advanced heart failure; therefore, it is better for these clients to receive care from an experienced nurse. The nurse prepares to administer the prescribed 8 AM medications to 4 clients. The nurse should administer medication to which client first? 1) Client 2 days postoperative abdominal surgery who is to receive enoxaparin for venous thromboembolism prophylaxis 2) Client with hypertension who has a blood pressure of 196/98 mm Hg and is to receive IV hydralazine 3) Client with suspected sepsis who has a temperature of 102.3 F (39.1 C) and is to receive an initial dose of IV ceftazidime 4) 0 4. Client with type 2 diabetes mellitus and blood sugar of 500 mg/dl (27.8 mmoi/L) who is to receive subcutaneous regular insulin and insulin glargine Correct answer- Option 3 Sepsis is a condition associated with a serious infection in the bloodstream. Evidence- based guidelines recommend the early administration of antibiotic therapy to reduce mortality. Cultures should be obtained quickly and antibiotics administered as soon as possible. Failure to treat early sepsis can lead to septic shock (persistent hypotension) and multiorgan dysfunction syndrome. (Option 1) Subcutaneous venous thromboembolism prophylaxis with enoxaparin following abdominal surgery is usually prescribed once every 24 hours, so administration is not urgent. (Option 2) This client has high blood pressure and needs treatment. However, this is not immediately life-threatening. If nausea, vomiting, and headache were also present, then the client would likely have hypertensive urgency or encephalopathy and need to be treated emergently. (Option 4) This client has high blood glucose and needs to be treated. However, it is not immediately life-threatening unless the client has hyperosmolar hyperglycemic syndrome or diabetic ketoacidosis The nurse receives news of a local mass shooting. Stable clients need to be discharged to make room for newly admitted clients. Which client would the nurse identify as safe to recommend for discharge? 1. Client on chemotherapy who started antibiotics today for cellulitis of the leg 2. Client with asthma exacerbation who has not required oxygen or a nebulizer in 12 hours 3. Client with diabetes who has nausea, abdominal pain, and vomiting 4. Client with ulcerative colitis and diarrhea who has developed fever and vomiting Submit Correct answer- Option 2 This client is the most stable, all other clients are not. The nurse has received report on the following clients. Which client should the nurse assess first? 1. Client 4 hours postoperative colon resection who has a blood pressure of 90/7 4 mm Hg 2. Client receiving palliative care who has Cheyne-Stokes respiration with 20-second periods of apnea 3. Client with anemia and hemoglobin level of 7 g/dl (70 g/L) who has a pulse of 11 0/min after ambulation 4. Client with diabetic ketoacidosis who has rapid, deep respirations at a rate of 32/min Correct answer- Option 1: The nurse should first assess the client who had bowel surgery as hypotension can be a manifestation of bleeding, hypovolemia, and early septic shock. The nurse should check vital signs and perform a cardiovascular assessment. (Option 2) Cheyne-Stokes respiration is a repetitive, abnormal, irregular breathing pattern characterized by alternating deep and shallow respirations followed by periods of apnea (10-20 seconds). The pattern is usually associated with certain neurologic conditions (eg, stroke, increased intracranial pressure) and with end of life; it would be expected in this client. (Option 3) Shortness of breath and tachycardia with activity related to decreased hemoglobin level, red cells, and oxygen-carrying capacity would be expected in a client with moderate to severe anemia. (Option 4) Kussmaul breathing is characterized by regular but rapid, deep respirations and is associated with conditions that cause metabolic acidosis (eg, renal failure, diabetic ketoacidosis, shock). Kussmaul breathing would be expected in this client as it is a compensatory action by the lungs to excrete excess acid from the body by hyperventilating, thereby blowing off carbon dioxide (acid gas). Educational objective: Postoperative hypotension can be a manifestation of bleeding, hypovolemia, and sepsis. Changes in vital signs (eg, decreased systolic pressure, tachycardia, tachypnea) and cool, pale skin can indicate decreased cardiac output and altered tissue perfusion A category 4 hurricane has disrupted a rural local health care system, creating a significant increase in emergency department admissions. Which client would the nurse assess first? 1. 55-year-old with type 2 diabetes mellitus complaining of a headache after being involved in a minor motor vehicle accident ' 2. 45-year-old with type 1 diabetes mellitus with a blood glucose of 690 mg/dl (38.3 mmoi/L) complaining of abdominal pain and fatigue 3. 7-year-old with status asthmaticus and an oxygen saturation of 89% 4. 34-year-old with gestational diabetes, 11 weeks pregnant, who has not been able to "hold anything down" due to nausea and vomiting over the past 2 days Correct answer- Option 3. Explanation: