NCLEX Secrets - Level of Cognitive Ability
16. An adult female client has a hemoglobin level of 10.8 g/dL. The nurse interprets that this result is most likely caused by which of the following conditions noted in the client's history?
a) dehydration
b) heart failure
c) iron deficiency anemia
d) chronic obstructive pulmonary disease
17. The nurse is teaching a client who has iron deficiency anemia about foods she should include in her diet. The nurse determines that the client understands the dietary modifications if she selects which of the following from her menu?
a) nuts and milk
b) coffee and tea
c) cooked rolled oats and fish
d) oranges and dark leafy vegetables
18. A client is being weaned from parenteral nutrition (PN) and is expected to begin taking solid food today. The ongoing solution rate has been 100 ml/hr. A nurse anticipates that which of the following orders regarding the PN solution will accompany the diet order?
a) discontinue the PN
b) decrease PN rate to 50 ml/hr
c) hang 1000 ml 0.9% normal saline
d) continue current infusion rate orders for PN
19. A client receiving parenteral nutrition (PN) complains of headache. A nurse notes that the client has an increased blood pressure, bounding pulse, jugular vein distention, and crackles bilaterally. The nurse interprets that the client is experiencing which complication of PN therapy.
a) sepsis
b) air embolism
c) hypervolemia
d) hyperglycemia
20. A nurse enters the room of a client receiving parenteral nutrition (PN) and discovers that the electronic infusion pump has been shut off. After checking the line for patency and restarting the infusion, the nurse assesses the client for which of the following signs and symptoms?
a) fever and chills
b) dyspnea and hypotension
c) weakness, thirst, and excessive urination
d) weakness, shakiness, diaphoresis, and complaints of hunger
NCLEX Secrets - Level of Cognitive Ability:
ANSWERS AND RATIONALE
16) C
- the normal hemoglobin level for an adult female client is 12 to 15 g/dL. Iron deficiency anemia can result in lower hemoglobin level. Dehydration may increase the hemoglobin level by hemoconcentration. Heart failure and chronic obstructive pulmonary disease may increase the hemoglobin level as a result of the body's need for more oxygen-carrying capacity.
17) D
- dark green leafy vegetables are a good source of iron and oranges are a good source of vitamin C, which enhances iron absorption. All other options are not food sources that are high in iron and vitamin C.
18) B
- when a client begins eating a regular diet after a period of receiving parenteral nutrition, the PN is decreased gradually. Parenteral nutrition that is discontinued abruptly can cause hypoglycemia. Clients often have anorexia after being without food for some time, and the digestive tract also is not used to producing the digestive enzymes that will be needed. Gradually decreasing the infusion rate allows the client to remain adequately nourished during the transition to a normal diet and prevents the occurrence of hypoglycemia. Even before clients are started on a solid diet, they are given clear liquids followed by full liquids to further ease the transition. A solution of normal saline will not provide the glucose needed during the transition of discontinuing the PN and also could cause the client to experience hypoglycemia.
19) C
- the client's sign and symptoms are consistent with hypervolemia. The increased intravascular volume increases the blood pressure, whereas the pulse rate increases as the heart tries to pump the extra fluid volume. The volume also causes neck vein distention and shifting of fluid into the alveoli, resulting in lung crackles. The signs and symptoms presented in the question do not indicate hyperglycemia, air embolism, or sepsis.
20) D
- If the pump that is infusing PN shuts off for a period of time, the nurse assesses the client for signs and symptoms of hypoglycemia. These signs include weakness, shakiness, headache, anxiety, diaphoresis, and complaints of hunger. The blood glucose level will be lower than 70 mg/dL. The other signs and symptoms described are those of infection (option A), air embolism (option B), and hyperglycemia (option C).
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