Unit Exam 7 NCLEX questions

A 30-year-old patient newly diagnosed with type 2 diabetes states to the nurse, "If glucose is so important, then I think as long as my blood sugar is high I must be doing well." What is the most appropriate response by the nurse? 1. "It depends on what you mean by high blood sugar. You will need to obtain more information from your provider as diabetes is a very complicated disease process." 2. "I understand how you are thinking; however, a high glucose level does not mean that there is more fuel available for your body's cells. Because you have diabetes, your body cells can't use the excess glucose." 3. "I will be able to explain this to you a little better when we talk about diabetes. For now, I have to finish my assessment, and then we can get back to your question." 4. "When I finish your assessment, I will teach you how to perform glucose testing. As long as your blood sugar remains somewhere in the 120-to-140 - answer-2."I understand how you are thinking; however, a high glucose level does not mean that there is more fuel available for your body's cells. Because you have diabetes, your body cells can't use the excess glucose." A 52-year-old man has a body mass index of 28.9, and his weight exceeds the ideal body weight for height by 23%. Which nursing diagnosis should the nurse identify for this patient? 1. Imbalanced Nutrition: More Than Body Requirements 2. Risk for Imbalanced Nutrition: More Than Body Requirements 3. Imbalanced Nutrition: Less Than Body Requirements 4. Readiness for Enhanced Nutrition - answer-1. Imbalanced Nutrition: More Than Body Requirements A client is concerned about the age-related changes of the client's mother, who is 80 years old. Which statements made by the client likely represent a normal change of aging? Select all that apply. 1. "My mother seems to get cold very easily." 2. "My mother complains of her mouth being dry." 3. "My mother goes around the house turning on all the lights." 4. "My mother complains of urine leaking when she coughs." 5. "My mother will only eat the food she personally prepares." - answer-1. "My mother seems to get cold very easily." 2. "My mother complains of her mouth being dry." 3. "My mother goes around the house turning on all the lights." A client tells the nurse, "I can't see well enough to read any more. I have new glasses, but it's still hard." What should the nurse advise her to do first? 1) Go back to the eye doctor and have him check your glasses. 2) Buy some audio books and listen to those. 3) Adapt to reading less and find a new leisure activity. 4) Install a bright but glare-free light near where she reads. - answer-4) Install a bright but glare-free light near where she reads A client who lives alone is very weak, stays in bed most of the time, and becomes fatigued after taking only two or three steps with a walker. The client's personal hygiene is poor. The client moves very slowly even during performance of small tasks, such as eating a meal. Which are appropriate interventions for this patient? Select all that apply. 1. Arrange for a home aide to assist with activities of daily living. 2. Refer the client to a senior center for an adapted physical activity program. 3. Assess the patient for symptoms of depression and memory loss. 4. Arrange for nutritious meals to be delivered to the patient's home. 5. Make arrangements for admission into an assisted care facility. - answer-1. Arrange for a home aide to assist with activities of daily living. 3. Assess the patient for symptoms of depression and memory loss. 4. Arrange for nutritious meals to be delivered to the patient's home. A couple is planning to move to a housing development that has been built to provide elder-friendly dwellings and environments for independent living. The houses are smaller and on a single level. Their purchase includes home maintenance and repair, snow and trash removal, a pool, and a walking track. Only people 60 years and older qualify to buy a house in this community. Medical and nursing care are not a part of the purchase. How would their living situation be described? 1) Naturally occurring retirement community 2) Retirement community 3) Continuing care retirement community 4) Assisted-living facilities - answer-2) Retirement community A couple who is considered middle-old adults is moving out of state to be closer to family members. Which residence is considered most appropriate for this couple? 1. Second story apartment with safety bars in the bathrooms 2. Small two-bedroom home close to a shopping center and a church 3. One-level living area condominium with good lighting inside and outside 4. Two-level living area condominium close to family members - answer-3. One-level living area condominium with good lighting inside and outside A group of pediatric nurses accepts an international assignment in an underdeveloped country. The nurses are informed that they will be caring for many children with kwashiorkor. The nurses will create a care plan focusing on which primary nutrient for these children? 1. Calories 2. Protein 3. Niacin 4. Vitamin C - answer-2. Protein A healthy client who is 80 years of age sees the nurse practitioner at the doctor's office. The client states, "I sit around a lot, and now I notice my legs seem to get tired when I walk." Which is the most appropriate response by the nurse? 1. "This indicates you don't have as good circulation as you did when you were younger." 2. "How do you feel about joining a regular exercise program at the senior center?" 3. "You will need to speak to the doctor about this; your age may cause health problems." 4. "Have you thought about using a cane or a walker to help you get around better?" - answer-2. "How do you feel about joining a regular exercise program at the senior center?" A middle-aged patient with a history of alcohol abuse is admitted with acute pancreatitis. Which nutrient level will most likely be the lowest? 1. Iron 2. B vitamins 3. Calcium 4. Phosphorus - answer-2. B vitamins A mother brings her 4-month-old infant for a well-baby checkup. The mother tells the nurse that she would like to start bottle feeding her baby because she cannot keep up with the demands of breastfeeding since returning to work. Which response by the nurse is appropriate? 1. "Make sure you give your baby an iron-fortified formula to supplement any stored breast milk you have." 2. "You really need to continue breastfeeding your baby." 3. "Give your baby formula until he is 6 months old; then you can introduce whole milk." 4. "Your baby weighs 14 pounds, so he will require about 36 ounces of formula a day." - answer-1. "Make sure you give your baby an iron-fortified formula to supplement any stored breast milk you have." A patient has anemia. An appropriate goal for that the patient would be for him to increase his intake of which nutrient? 1) Calcium 2) Magnesium 3) Potassium 4) Iron - answer-4) Iron A patient has been admitted to the hospital with medical diagnoses of hypervolemia, acute renal failure, and cardiac dysrhythmias. The patient's vital signs are: T = 98.4°F (36.9°C); P = 110; R = 32; BP = 162/102. On physical examination, the nurse notes distended neck veins and 3+ pitting edema in both lower extremities. The patient reports he has been drinking and eating as usual but has been unable to urinate. Which is the most appropriate nursing diagnosis for this patient? 1) Excess Fluid Volume related to excessive food and fluid intake 2) Deficient Fluid Volume related to increased metabolic demands 3) Imbalanced Electrolytes secondary to fluid shifts 4) Excess Fluid Volume secondary to acute renal failure - answer-4) Excess Fluid Volume secondary to acute renal failure A patient is brought to the emergency department (ED) by paramedics after a bystander saw him fall on a crowded street. He has a history of alcoholism and is frequently brought to the ED. The nurse finds the patient to be disoriented; he has periods of being calm mixed with episodes of being disruptive and loud. His vital signs are the following: BP, 138/84 mm Hg; pulse, 135 beats/min, regular and strong; respiratory rate, 22 breaths/min; temperature, 37.1°C (98.1°F). What electrolyte imbalance might the nurse suspect? 1) Hypomagnesemia 2) Hyypocalcemia 3) Hyperkalemia 4) Hypernatremia - answer-1) Hypomagnesemia A patient is in respiratory distress. The provider has ordered arterial blood gases (ABGs). The results are the following: pH = 7.50; PCO2 = 26; HCO3 = 24 mEq/L. How should the nurse interpret the ABGs? 1) Respiratory acidosis 2) Respiratory alkalosis 3) Metabolic acidosis 4) Metabolic alkalosis - answer-2) Respiratory alkalosis A patient is to receive two units of packed red blood cells. Her blood group is O+. The nurse knows that the patient may receive blood from which of the following donors? 1) AB+, A-, B+, and O- 2) A+ and O+ 3) AB- and O+ 4) O+ and O- - answer-4) O+ and O- A patient was brought to the emergency department with complaints of extreme fatigue, nausea, vomiting, and muscle weakness. Lab results reveal the following: Na+ = 140 mEq/L; K+ = 2.0 mEq/L; Ca2+ = 8.6 mg/dL; Mg2+ = 1.6 mg/dL; and Cl- = 96 mEq/L. The electrocardiogram (ECG) tracing has a flat T wave and frequent PVCs (premature ventricular contractions). The patient's prescribed daily oral medications include furosemide 20 mg, digoxin 0.25 mg, and aspirin 81 mg. The nurse recognizes that these symptoms and diagnostic information are consistent with which of the following? 1) Hypocalcemia 2) Hypernatremia 3) Hypokalemia 4) Hypermagnesemia - answer-3) Hypokalemia A patient was brought to the emergency department with complaints of extreme fatigue, nausea, vomiting, and muscle weakness. Lab results reveal the following: Na+ = 140 mEq/L; K+ = 2.0 mEq/L; Ca2+ = 8.6 mg/dL; Mg2+ = 1.6 mg/dL; and Cl- = 96 mEq/L. The electrocardiogram (ECG) tracing has a flat T wave and frequent PVCs (premature ventricular contractions). The patient's prescribed daily oral medications include furosemide 20 mg, digoxin 0.25 mg, and aspirin 81 mg. Why should the nurse question the order for digoxin 0.25 mg orally daily? 1) Based on the digoxin level, the dose may need to be increased. 2) The patient is at risk for an elevated digoxin level at this time. 3) Digoxin and furosemide should never be taken together. 4) The nurse should not be concerned about the order as written. - answer-2) The patient is at risk for an elevated digoxin level at this time. A patient who is 85 years of age is admitted through the emergency department for confusion and disorientation. The family states, "We don't know what is wrong. He has been fine at home. This confusion just started 2 days ago and seems like it is getting worse." What is the most appropriate first response for the nurse to make? 1. "We will have to place him in temporary restraints for safety purposes." 2. "Can you tell me about his home medications and other illnesses he has?" 3. "Sometimes older people become more confused when they are away from home." 4. "He is 85 years old, and this is the age when Alzheimer's disease begins." - answer-2. "Can you tell me about his home medications and other illnesses he has?" A patient who underwent surgery 24 hours ago is prescribed a clear liquid diet. The patient asks for something to drink. Which item may the nurse provide for the patient? 1. Vanilla shake 2. Orange juice 3. Grape juice 4. Skim milk - answer-3. Grape juice A patient who was prescribed furosemide is deficient in potassium. Which nutritional goal is appropriate for this patient? The patient will increase consumption of: 1. Avocados, peaches, molasses, and potatoes 2. Eggs, celery, baking soda, and baking powder 3. Wheat bran, chocolate, eggs, and sardines 4. Egg yolks, nuts, broccoli, and sardines - answer-1. Avocados, peaches, molasses, and potatoes A patient with trigeminal neuralgia is prescribed a mechanical soft diet. This diet places the patient at risk for which complication? 1. Dehydration 2. Constipation 3. Hyperglycemia 4. Diarrhea - answer-2. Constipation A patient's parenteral nutrition (PN) container infuses before the pharmacy prepares the next container. This places the patient at risk for which complication? 1. Sepsis 2. Aspiration 3. Hypoglycemia 4. Diarrhea - answer-3. Hypoglycemia A physician has prescribed 1,000 ml of 0.9% NaCl (normal saline) over 4 hours for a hypovolemic patient. The drop (gtt) factor is 60. What would the nurse set the drip rate at? 1) 75 gtt/min 2) 100 gtt/min 3) 250 gtt/min 4) 500 gtt/min - answer-3) 250 gtt/min A white female patient who is 75 years of age states, "I've heard that women live to an older age than men. My husband and I are the same age, so I am afraid I will have to spend some years without him. This really worries me." Which answer by the nurse is based on correct information? 1. "That is a realistic concern as women do have a longer life expectancy than men. But many things can happen to change that." 2. "You need not worry because both you and your husband are white. That statistic is true only for black men and women." 3. "It is true that women have a longer life expectancy at birth. However, life expectancy measured at age 65 is almost the same for both sexes. You are both well past 65." 4. "That is true only in certain geographical areas, such as those with a high population of newly retired persons." - answer-"It is true that women have a longer life expectancy at birth. However, life expectancy measured at age 65 is almost the same for both sexes. You are both well past 65." After inserting a nasogastric feeding tube, what would be the nurse's priority action prior to starting the first tube feeding? 1. Auscultate bowel sounds over the abdomen. 2. Aspirate gastric contents and obtain a pH reading. 3. Obtain radiographic verification (x-ray). 4. Mix the feeding with water for the first feeding only. - answer-3. Obtain radiographic verification (x-ray). After instructing a mother about nutrition for a preschool-age child, which statement by the mother indicates correct understanding of the topic? 1. "I usually use dessert only as a reward for eating other foods." 2. "I will make sure my child gets at least 2,000 kcal/day." 3. "I do not give my child snacks; they simply spoil the appetite for meals." 4. "I know that lifelong food habits are developed during this stage of life." - answer-4. "I know that lifelong food habits are developed during this stage of life." An 86-year-old patient had prostate surgery 2 days ago. Which nursing action best meets his developmental needs? 1) Perform a spiritual assessment and make referrals as needed. 2) Provide a complete bed bath and other hygiene needs. 3) Encourage the patient to perform self-care as much as possible. 4) Administer pain medications to keep the patient comfortable - answer-3) Encourage the patient to perform self-care as much as possible An adult patient who is receiving a continuous enteral feeding at 80 ml/hr has a residual volume of 120 ml 6 hours after the last check. How should the nurse proceed? 1) Continue administering the enteral feeding. 2) Hold the enteral feeding and notify the provider immediately. 3) Hold the feeding for 1 hour, and recheck. 4) Hold the feeding for 2 hours, then resume the feeding. - answer-3) Hold the feeding for 1 hour, and recheck An elderly female, adequately nourished, was admitted to the skilled nursing facility 3 months ago. Since then, she has had a significant weight loss and has become weak. Her appetite and activity level are reduced, and she has lost interest in interacting with other patients. What would the nurse suspect the reason for her condition to be? 1. Need for teaching about nutrition 2. Anxiety 3. Distaste for the food served 4. Frail elderly syndrome - answer-4. Frail elderly syndrome Chloride, bicarbonate, phosphate, and sulfate are examples of what type of charged particles and why? 1) Cations, because they carry a positive charge 2) Cations, because they carry a negative charge 3) Anions, because they carry a positive charge 4) Anions, because they carry a negative charge - answer-4) Anions, because they carry a negative charge During an admission assessment, the patient reports that he takes vitamin E supplements twice a day. The nurse should explain that taking vitamin E supplements twice a day 1) ensures healthy vision. 2) can lead to toxicity. 3) strengthens the immune system. 4) helps maintain body tissues. - answer-2) can lead to toxicity. During parenteral nutrition administration, a nurse breaks sterile technique. For which complication does this place the patient at risk? 1) Air embolism 2) Sepsis 3) Thrombosis 4) Pneumothorax - answer-2) Sepsis