NCLEX RN practice test NGN questions and answers with rationales

NCLEX RN practice test NGN questions and answers with rationales the nurse provides care for a client who is prescribed assist control mechanical ventilation with PEEP of 5 cm H20. Which action will the nurse include in the client's plan of care? SATA - ANS--strict handwashing before suctioning - administer pantoprazole 40 mg intravenous daily - change client position every 2 hrs Rationale- *** pantoprazole a proton pump inhibitor(PPI) wil decrease the risk of aspiration of gastric contents. the nurse reviews the record of a client diagnosed with acute kidney injury (AKI). It is most important for the nurseto review which lab value? - ANS-URINE SPECIFIC GRAVITY Rationale- *** specific gravity can indicate fluid volume excess or deficit and is the most important of the lab values to assess a client is admitted for dehydration. the nurse observed that the client appears restless and reports difficulty breathing. The nurse auscultes the client's lungs and hears bilateral basilar crackles. Which action does the nurse take first? - ANS-ELEVATE THE HEAD OF THE BED AND STOP THE iv INFUSION Rationale-*** it addresses the clients difficulty breathing and indications of fluid volume overload A client diagnosed with chronic lymphocytic leukemia (CLL) is scheduled for a bone marrow aspiration biospy. The client says "I am frightened I have never had this test before and I dont know what to expect." Which statement will the nurse include when responding to the client's concerns? SATA - ANS-*** Rationale- "A tight pressure dressing will be placed over the test site after the procedure" -There is a risk of bleeding so will monitor the test site frequently BM biopsy - ANS-- can be done in pt room or treatment room Rationale-pressure dressing applied to reduce rf bleeding -stinging and discomfort furing biopsy is expected -monitor for bleeding -local anesthetic used a client diagnosed with malnutrition is prescribed continuous enteral feedings through a newly placed gastrostomy tube. Which action does the nurse include in the client's plan of care? SATA - ANS-- rotate the gastrostomy tube 360 degrees once daily - check for a slight in-and-out movement of the gastrostomy tube Rationale **** 4-8 hrs of enteral feeding should be added to the bag to reduce contamination. the tube should be rotated 560 daily to reduce skin irritation