NCLEX FUNDAMENTALS II EXAM WITH RATIONAL

NCLEX FUNDAMENTALS II EXAM WITH RATIONAL A health care provider's prescription reads potassium chloride 20 mEq in 1000 mL normal saline and infuse at 100 mL/hr. The nurse assisting in caring for the client determines that the client will receive how many milliequivalents (mEq) of potassium every hour? Fill in the blank. Rationale: Use the ratio and proportion formula to solve this problem, and then solve for x. 20 mEq: 1000 mL :: x mg: 100 mL Multiply means and extremes then divide to solve for x. 1000x = 2000x = 2 mEq Penicillin V 250 mg orally every 8 hours, is prescribed for a child with a respiratory infection. The child's weight is 45 pounds. The safe pediatric dosage is 25 to 50 mg/kg/day. Which statement accurately describes the prescribed dosage for this child? Rationale: Convert pounds to kilograms by dividing by 2.2 and then determine the dosage frequency.Pounds to kilograms:45 lb ÷ 2.2 lb/kg = 20.45 kgDosage parameters:25 mg/kg/day × 20.45 kg = 511.25 mg/day50 mg/kg/day × 20.45 kg = 1022.5 mg/dayDosage frequency:250 mg × 3 doses (every 8 hours) = 750 mg/dayThe dosage is within the safe dosage range. The nurse is assigned to care for an Asian-American client. The nurse develops a plan of care based on which belief? Rationale: Asian Americans believe that illness is caused by an imbalance between yin and yang, by prolonged sitting or lying, or by overexertion. In the African-American culture, illness is viewed as a disharmonious state that may be caused by demons and spirits. Native Americans believe that illness is caused by supernatural forces. An anxious client is experiencing respiratory alkalosis from hyperventilation as a result of anxiety. The nurse should do which action to help the client experiencing this acid-base disorder? Rationale: An anxious client benefits from emotional support and reassurance, which in turn reduces anxiety and may lower the respiratory rate. The client may benefit from the administration of a sedative or antianxiety medication, if it is prescribed. The client should try to breathe more slowly and shallowly. Lying supine provides no benefit to the client. The nurse is assisting in the care of a client receiving codeine sulfate for pain. The nurse should make note of which finding to detect an adverse effect of this medication? Rationale: The client taking codeine sulfate is at risk for constipation. Thus, the nurse monitors the frequency of bowel movements. The nurse also would monitor the client for hypotension, decreased respirations, and urinary retention. The nurse would plan measures to counteract these expected effects such as encouraging fluids, coughing and deep breathing, and increasing mobility to the extent tolerated by the client. A client who takes theophylline (Theo-24) for chronic obstructive pulmonary disease (COPD) is seen in the health care clinic. A theophylline level is drawn, and the nurse determines that the client is compliant with the medication regimen if which laboratory result is reported? Test-Taking Strategy: Focus on the subject, administration of theophylline, and note the word compliant. Familiarity with the therapeutic level of theophylline is needed to select the correct option. Remember that the therapeutic range for the serum theophylline level is 10 to 20 mcg/mL. Review: Therapeutic range of theophylline. The health care provider prescribes ibuprofen (children's Motrin) 5 mg per kg for a child who weighs 13 pounds. How many milligrams (mg) should the nurse administer to the child? Fill in the blank. Record your answer using one decimal place. Rationale: A child who weighs 13 pounds weighs 5.9 kg. This is determined by dividing 13 by 2.2 to obtain the weight in kilograms (1 kg = 2.2 lb). Once that is determined, 5.9 is multiplied by 5 mg to yield 29.5 mg. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process: Implementation Content Area: Fundamental Skills: Medication/IV Calculations Strategy(ies): Subject Priority Concepts: Clinical Judgment, Safety Diphenhydramine hydrochloride (Benadryl) 25 mg orally every 6 hours is prescribed for a child with an allergic reaction. The child weighs 25 kg. The safe pediatric dosage is 5 mg/kg/day. What should the nurse determine about the medication dosage? Rationale: Calculate the dosage parameters using the safe dosage range identified in the question and the child's weight in kilograms. Next, determine the total daily dosage.Dosage parameters: 5 mg/kg × 25 kg = 125 mg/dayDosage frequency: 25 mg × 4 doses = 100 mg/dayThe dosage is safe. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Data Collection Content Area: Fundamental Skills: Medication/IV Calculations Strategy(ies): Subject Priority Concepts: Clinical Judgment, Safety A health care provider's prescription reads triazolam (Halcion), 125 mcg orally at bedtime daily. The medication bottle is labeled triazolam, 0.125-mg tablets. The nurse prepares how many tablet(s) to administer 1 dose? Fill in the blank. Rationale: Convert 125 mcg to mg. In the metric system, to convert smaller to larger, divide by 1000 or move the decimal three places to the left. Therefore, 125 mcg = 0.125 mg. One tablet is administered. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process: Planning Content Area: Fundamental Skills: Medication/IV Calculations Strategy(ies): Subject Priority Concepts: Clinical Judgment, Safety A child with leukemia is experiencing nausea related to medication therapy. The nurse, concerned about the child's nutritional status, should offer which during an episode of nausea? Rationale: When the child is nauseated, it is best to offer frequent intake of cool, clear liquids in small amounts because small portions are usually better tolerated. Cool, clear fluids are also soothing and better tolerated when a client is nauseated. It is best not to offer favorite foods when the child is nauseated because foods eaten during times of nausea will be associated with being sick. It is best to offer small, frequent meals of high-protein and high-calorie content once the nausea has been controlled with medication or has subsided. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process: Implementation Content Area: Fundamental Skills: Nutrition Strategy(ies): Subject Priority Concepts: Cellular Regulation, Nutrition The nurse is caring for an older client who had a hip pinned after being fractured. In planning nursing care, which should the nurse avoid to minimize the chance for further injury? Rationale: Safe nursing actions intended to prevent injury to the client include keeping side rails up, having the bed in a low position, and providing a call bell that is within the client's reach. Responding promptly to the client's use of the call light minimizes the chance that the client will try to get up alone, which could result in a fall. Level of Cognitive Ability: Applying Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process: Implementation Content Area: Fundamental Skills: Safety Strategy(ies): Subject Priority Concepts: Clinical Judgment, Safety The nurse is caring for a client with kidney failure. The nurse is told that the blood gas results indicate a pH of 7.30 and a HCO3– of 20 mm Hg, and that the client is experiencing metabolic acidosis. The nurse reviews the laboratory results and expects to note which? Rationale: Signs/symptoms of metabolic acidosis include weakness, malaise, and headache. Hyperkalemia will occur because the cells will draw hydrogen into the cell and in exchange will push potassium out of the cell into the blood. The pH will be lower than 7.35, and the HCO3– ion level will be lower than 22 mEq/L. The remaining options identify normal laboratory values, whereas a potassium level of 5.6 mEq/L indicates hyperkalemia. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Data Collection Content Area: Fundamental Skills: Acid-Base Strategy(ies): Comparable or Alike Options Priority Concepts: Clinical Judgment, Acid-Base Balance A clear liquid diet has been prescribed for a client with gastroenteritis. Which item is appropriate to offer to the client? Rationale: A clear liquid diet consists of foods that are relatively transparent. Soft custard and orange juice would be included in a full liquid diet because they are opaque, not clear. Clam chowder is opaque and also includes pieces of clams, thus eliminating it from a full liquid diet. Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Nursing Process: Implementation Content Area: Fundamental Skills: Nutrition Strategy(ies): Subject Priority Concepts: Inflammation, Nutrition The chart describes characteristics of various types of enemas. Which type of enema has the highest risk of complications? Refer to chart. View Chart Rationale: Tap water is hypotonic, creating a lower osmotic pressure than the fluid in interstitial spaces. With repeated tap water enemas, fluid can escape from the bowel lumen into interstitial spaces and can cause circulatory overload if the body absorbs too much water. Normal saline enemas are the safest type of enema because of having the same osmotic pressure as fluid in the interstitial spaces around the bowel. Thus, enemas using normal saline do not cause any fluid shifts. Castile soap is incorrect because it can be mixed with either water or saline, and if mixed with saline, there should not be any risk of fluid overload. Castile soap is the only safe soap to use for a soapsuds enema because harsh soaps may cause inflammation of the bowel. Hypertonic solution is incorrect because hypertonic fluids pull fluid from the interstitial spaces into the colon. Although this could have the potential for dehydration, it does not pose as high of risk of complications as the tap water enema. A Fleets enema is the most common type of hypertonic enema. Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Integrated Process: Nursing Process: Data Collection Content Area: Fundamental Skills: Elimination Strategy(ies): Subject Priority Concepts: Clinical Judgment, Elimination The nurse needs to increase the calcium in the diet of a client who is lactose intolerant. Which food items should the nurse encourage? Select all that apply. Rationale: Lactose-intolerant clients should not eat dairy products. Therefore, these clients need high- calcium foods from nondairy sources. Tofu, broccoli, mustard greens, and sardines are foods that are high in calcium that do not come from dairy sources. Although milk and cheese are high in calcium, they are dairy products, which lactose-intolerant clients need to avoid.