NCLEX Review Respiratory Questions (46-50)

NCLEX Review Respiratory Questions

46. Which of the following assessment findings in a client with a closed chest tube drainage should concern the nurse most?

a) continuous, vigorous bubbling in the suction control chamber
b) continuous, gentle bubbling in the suction control chamber
c) continuous fluctuations of fluid along the tube in the water-seal chamber
d) absence of bubbling in the water-seal chamber

47. A 4-year old female client is brought to the emergency room after waking up with bark-like cough and stridor. On arrival to the ER, she has respiratory distress and is afebrile. The diagnosis is croup. What instruction should you give the parents?

a) perform percussion and postural drainage before putting the child to bed and before meals
b) run a cool mist vaporizer in patient's room during the day
c) encourage the child to do coughing and deep breathing exercises
d) bring the child to the bathroom and have the tap run with warm water during acute episodes of cough  

48. Which of the following teachings should be given to the mother when her child is in a mist tent for liquefication of secretions?

a) give the child a stuff toy inside the mist tent
b) avoid nylon blanket inside the mist tent
c) advise mother to let the child stay in the mist tent
d) give the child coloring book inside the mist tent

49. A nurse assesses a client with a chest tube who is restless and diaphoretic, and has a temperature of 101.2 F. The client reports pain at the chest tube site. Which action should the nurse take first?

a) administer pain medication
b)auscultate the client's lungs
c) check the client's blood pressure and pulse
d) check the chest tube dressing and tubing

50. A nurse has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate?

a) inform the physician
b) continue to monitor the client
c) reinforce the occlusive dressing
d) encourage the client to deep-breathe





NCLEX Review Respiratory Questions:
ANSWERS AND RATIONALE

46) A
- vigorous bubbling in the suction control chamber indicates that the pressure of suction is very high. This may cause trauma to the pleura, and should concern the nurse. Options B, C, and D are normal findings.

47) B
- cool mist vaporizer will relieve spasm of airways. This will promote easy breathing of the child with croup.

48) C
- a child should stay inside the mist tent to liquefy mucous secretions and facilitate breathing. Toys that absorb moisture like stuff toys and coloring book should be avoided. Dampness lowers resistance to infection.

49) B
- assessment of the respiratory status is a priority among clients with chest tube.

50) B
- the presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if a dependent loop exists. If the suction is not working properly, or if the lung has re-expanded. Option A, C, and D are incorrect. 


Go to the next page ---> NCLEX Review Respiratory Questions (51-55)  

Or go back to NCLEX Review Respiratory Questions (1-6) to start the test from the beginning.

Read More

NCLEX Secrets - Level of Cognitive Ability (Analysis 36-40)

NCLEX Secrets - Level of Cognitive Ability

36. A nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site?

a) red, hard skin
b) serous drainage
c) purulent drainage
d) warm, tender skin

37.A nurse is monitoring the status of a postoperative client. The nurse would become most concerned with which of the following signs that could indicate an evolving complication?

a) increasing restlessness
b) a negative Homan's sign
c) hypoactive bowel sounds in all four quadrants
d) a blood pressure of 110/70 mmHg and a pulse of 86 bpm  

38. A nurse is reviewing a physician's order sheet for a preoperative client that states that the client must be NPO after midnight. The nurse would telephone the physician to clarify that which of he following medications should be given to the client and not withheld?

a) ferrous sulfate
b) prednisone (deltasone)
c) cyclobenzaprine (flexeril)
d) conjugated estrogen (premarin)

39. A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which of the following results should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed?

a) sodium, 141 mEq/L
b) hemoglobing, 8.0 g/dL
c) platelets, 210,000 mm3
d) serum creatinine, 0.8 mg/dL

40. A nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which of the following parameters most carefully during the next hour?

a) urinary output of 20 ml/hr
b) temperature of 37.6 C (99.6F)
c) blood pressure of 100/70 mmHg
d) serous drainage on he surgical dressing





NCLEX Secrets - Level of Cognitive Ability:
ANSWERS AND RATIONALE

36) B
- serous drainage is expected finding at a surgical site. The other options indicate signs of wound infection. Signs and symptoms of infection include warm, red, and tender skin around the incision. Purulent material may exit from drains or from separated wound edges. Infection may be caused by poor aseptic technique and a contaminated wound before surgical exploration. Wound infection usually appears 3 to 6 days after surgery. The client also may have a fever and chills.

37) A
- increasing restlessness is a sign that requires continuous and close monitoring because it could indicate a potential complication such as hemorrhage, shock or pulmonary embolism. Hypoactive bowel sounds heard in all quadrants are a normal occurrence, as in a negative Homan's sign. (A positive Homan's sign may indicate thrombophlebitis.) A blood pressure of 110/70 mmHg with a pulse of 86 bpm is within normal limits.

38) B
- prednisone is a corticosteroid. With prolonged use, corticosteroids cause adrenal atrophy, which reduces the ability of the body to withstand stress. When stress is severe, corticosteroids are essential to life. Before and during surgery, dosages may be increased temporarily. Ferrous sulfate is an oral iron preparation used to treat iron deficiency anemia. Cyclobenzaprine is a skeletal muscle relaxant. Conjugated estrogen is an estrogen used for hormone replacement therapy in postmenopausal women. These other three medications may be withheld before surgery without undue effects on the client.

39) B
- routine screening tests include a complete blood count, serum electrolyte analysis, coagulation studies, and serum creatinine tests. The complete blood count includes the hemoglobin analysis. All these values are within normal range, except the hemoglobin. If a client has a low hemoglobin level, the surgery likely could be postponed by the surgeon.

40) A
- urine output should be maintained at a minimum of 30 ml/hr for an adult. An output of less than 30 ml for each of 2 consecutive hours should be reported to the physician. A temperature higher than 37.7C (100F) or lower than 36.1C (97F) and a falling systolic blood pressure, lower than 90 mmHg, are usually considered reportable immediately. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderate or light serous drainage from the surgical site is considered normal.


PREVIOUS [---------------------] NEXT -> COGNITIVE ABILITY  41-45 --&gt


Related Topics:

• Fundamentals of Nursing  Concepts
• Medical-Surgical Concepts
• Maternal and Child Concepts

Read More

NCLEX Secrets - Level of Cognitive Ability Analysis (31-35)

NCLEX Secrets - Level of Cognitive Ability

31. The nurse enters a client's room to assess the client, who began receiving a blood transfusion 45 minutes earlier, and notes that the client is flushed and dyspneic. On assessment, the nurse auscultates the presence of crackles in the lung bases. The nurse determines that his client most likely is experiencing which complication of blood transfusion therapy?

a) bacteremia
b) hypovolemia
c) fluid overload
d) transfusion reaction

32. A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most form this therapy if the client exhibits which of the following?

a) increased hematocrit level
b) increased hemoglobin level
c) decline of elevated temperature to normal
d) decreased oozing of blood from puncture sites and gums

33. The nurse listening to morning reports learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which of the following daily serum laboratory studies to assess the effectiveness of the transfusion?

a) hematocrit level
b) erythrocytes count
c) hemoglobin level
d) white blood cell count

34. A client is brought to the emergency room having experienced blood loss related to an arterial laceration. Fresh frozen plasma (FFP) is ordered and transfused to replace fluid and blood loss. The nurse understands that he rationale for transfusing FFP in this client is to:

a) treat the loss of platelets
b) promote rapid volume expansion
c) that the transfusion must be done slowly
d) that it will increase the hemoglobin and hematocrit levels

35. A nurse obtains an order from a physician to restrain a client by using a jacket restraint and instructs a nursing assistant to apply the restraint to the client. Which observation by the nurse indicates inappropriate application of the restraint by the nursing assistant?

a) a safety knot in the restraint straps
b) restraint straps that are safely secured to the side rails
c) jacket restraint straps that do not tighten when force is applied against them
d) jacket restraint secured so that two fingers can slide easily between the restraint and th client's skin





NCLEX Secrets - Level of Cognitive Ability:
ANSWERS AND RATIONALE

31) C
- with fluid overload, the client has the presence of crackles in addition to dyspnea. An allergic reaction, which is one type of blood transfusion reaction, would produce symptoms such as flushing, dyspnea, itching, and generalized rash. Hypovolemia is not a complication of blood transfusion. With bacteremia, the client would have a fever, which is not part of the clinical picture presented.

32) D
- platelet are necessary for proper blood clotting. The client with insufficient platelets may exhibit frank bleeding or oozing of blood from puncture sites, wounds, and mucous membranes. Increased hemoglobin and hematocrit levels would occur when the client has received a transfusion of red blood cells. An elevated temperature would decline to normal after infusion of granulocytes if those cells were instrumental in fighting infection in the body.

33) D
- the client who has neutropenia may receive a transfusion of granulocytes or white blood cells. These clients often have severe infections and are unresponsive to antibiotic therapy. The nurse notes the results of follow-up white blood cell counts to evaluate the effectiveness of the therapy. The nurse also continues to monitor the client for signs and symptoms of infection. Erythrocyte count and hemoglobin and hematocrit levels are determined after transfusion of packed RBC.

34) B
- fresh frozen plasma is often used for volume expansion as a result of fluid and blood loss. It does not contain platelets, so it is not used to treat any type of low platelet count disorder. It is rich in clotting factors and can be thawed quickly and transfuse quickly. It will not specifically increase the hemoglobin and hematocrit level.

35) B
- the restraint straps are secured to the bed frame and never to the side rail to avoid accidental injury in the event that the side rail is released. A half-bow or safety knot should be used for applying a restraint because it does not tighten when force is applied against it and it allows quick and easy removal of the restraint in case of an emergency. The jacket restraint should be secure, and one to two fingers should slide easily between the restraint and the client's skin.


PREVIOUS [---------------------] NEXT -> COGNITIVE ABILITY  36-40 --&gt


Related Topics:

• Fundamentals of Nursing  Concepts
• Medical-Surgical Concepts
• Maternal and Child Concepts

Read More

NCLEX Secrets - Level of Cognitive Ability (Analysis 26-30)

NCLEX Secrets - Level of Cognitive Ability

26. A client is hypovolemic and plasma expanders are not available. The nurse anticipates that which of the following solutions available on the nursing unit will be prescribed by the physician?

a) 5% dextrose in water
b) 0.9% sodium chloride
c) 0.45% sodium chloride
d) 5% dextrose in 0.45% sodium chloride

27. The nurse hears an attending physician asking an intern to prescribe a hypotonic intravenous (IV) solution for a client. Which of the following IV solutions would the nurse expect the intern to prescribe?

a) 5% dextrose in water
b) 10% dextrose in water
c) 0.45% sodium chloride
d) 5% dextrose in 0.9% sodium chloride

28. A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The nurse takes the client's blood pressure and it is 90/50 mm Hg, from a baseline of 125/78 mm Hg. The client's temperature is 100.8F orally, from a baseline of 99.2F orally. The nurse determines that the client may be experiencing which complication of a blood transfusion?

a) septicemia
b) hyperkalemia
b) circulatory overload
d) delayed transfusion reaction

29. The nurse is told by a physician that a client in hypovolemic shock will require plasma expansion. The nurse anticipates receiving an order to transfuse which product?

a) albumin
b) platelets
c) cryoprecipitate
d) packed red blood cells

30. A physician tells a client that the client needs a blood transfusion and that the blood sample must be drawn first for blood typing and crossmatching. After the physician leaves, the client asks the nurse, "What exactly is blood type, anyway?" The nurse responds with which of the following statements?

a) the blood type represents an antigen found on the surface of the red blood cells
b) the blood type represents an antibody found on the surface of the red blood cells
c) the blood type represents an antibody that normally circulates in the blood plasma
d) the blood type represents an antigen that normally circulates in the blood plasma





NCLEX Secrets - Level of Cognitive Ability:
ANSWERS AND RATIONALE

26.D
- a solution of 5% dextrose in 0.45% sodium chloride is hypertonic. An advantage of hypertonic solutions is that they may be used to treat hypovolemia when plasma expanders are not readily available. Options A and B are isotonic solutions. Option C is a hypotonic solution.

27) C
- hypotonic solutions contain a lower concentration of salt or more water than an isotonic solution. A solution of 0.45% sodium chloride is hypotonic. A solution of 5% dextrose in water (D5W) is isotonic. Solutions of 10% dextrose in water (D10W) and 5% dextrose in 0.9% sodium chloride are hypertonic solutions.

28) A
- septicemia occurs with transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and the development of shock. Hyperkalemia causes weakness, paresthesias, abdominal cramps, diarrhea, and dysrhythmias. Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. A delayed transfusion reaction can occur days to years after transfusion. Signs include fever, mild jaundice, and decreased hematocrit level.

29) A
- albumin may be used as plasma expander. Platelets are used when the client's platelet count is low. Cryoprecipitate is useful in treating bleeding from hrmophilia or disseminated intravascular coagulopathy because it is rich in clotting factors. Packed RBC replace erythrocytes and not a plasma expander.

30) A
- the major blood types are A, B, AB, and O. The blood type indicates an antigen found on the surface of the red blood cell. Acute hemolytic transfusion reaction (ABO incompatibility) can occur if a client receives blood that is not compatible with his or her blood type. Acute hemolytic reaction is the most serious adverse reaction to a blood transfusion.


PREVIOUS [---------------------] NEXT -> COGNITIVE ABILITY  31-35 --&gt


Related Topics:

• Fundamentals of Nursing  Concepts
• Medical-Surgical Concepts
• Maternal and Child Concepts

Read More

NCLEX Secrets - Level of Cognitive Ability (Analysis 21-25)

NCLEX Secrets - Level of Cognitive Ability

21. A client receiving parenteral nutrition (PN) in the home setting has a weight gain of lb in 1 week. The nurse next assesses the client to detect the presence of which of the following?

a) thirst
b) polyuria
c) decreased blood pressure
d) crackles on auscultation of the lungs

22. A nurse is caring for a group of adult clients on an acute care medical-surgical unit. The nurse understands that which of the following clients would be the least likely candidate for parenteral nutrition (PN)?

a) a 66-year old client with extensive burns
b) a 42-year old client who has an open cholecystectomy
c) a 27-year old client with severe exacerbation of Crohn's disease
d) a 35-year old client with persistent nausea and vomiting from chemotherapy.  

23. A client involved in a motor vehicle crash presents to the emergency department with severe internal bleeding. The client is severely hypotensive and unresponsive. The nurse anticipates that which of the following intravenous solutions will most likely be prescribed to increase intravascular volume, repalce immediate blood loss, and increase blood pressure?

a) 0.45% sodium chloride
b) 0.33% sodium chloride
c) 0.225% sodium chloride
d) lactated ringer's solution

24. The nurse is making initial rounds on the nursing unit to assess the conditon of assigned clients. The nurse notes that a client's intravenous (IV) site is cool, pale, and swollen, and the solution is not infusing. The nurse concludes that which of the following complications has been experienced by the client?

a) infection
b) phlebitis
c) infiltration
d) thrombosis

25. The nurse notes that the site of a client's peripheral intravenous (IV) catheter is reddened, warm, painful, and slightly edematous proximal to the insertion point of the IV catheter. After taking approximate steps to care for client, the nurse documents in the medical record that the client expericed:

a) phlebitis of the vein
b) infiltration of the IV lin
c) hypersensitivity to the IV solution
d) allergic reaction to the IV catheter material




NCLEX Secrets - Level of Cognitive Ability:
ANSWERS AND RATIONALE

21) D
- optimal weight gain on PN is 1 to 2 lb/week. The client who has a weight gain of 5 lb/week while receiving PN is likely to have fluid retention that can result in hypervolemia. Signs of hypervolemia include increased blood pressure, crackles on lung auscultation, a bounding pulse, jugular vein distention, headache, and weight gain more than desired. Options A and B are associated with hyperglycemia. Option C is likely to be noted in deficient fluid volume.

22) B
- parenteral nutrition is indicated in clients whose gastrointestinal tracts are not functional or who cannot take in a diet enterally for extended periods. Examples of these conditions include those of the clients identified in option A, C, and D. Other clients would be those who have had extensive surgery, have multiple fractures, are septic, or have advanced cancer or AIDS. The client with the open cholecystectomy is not a candidate because this client would resume regular diet within few days following surgery.

23) D
- the goal of therapy with this client is to expand intravascular volume as quickly as possible. Lactated ringer's (hypertonic solution) would increase intravascular volume and immediately replace lost fluid volume until a transfusion could be administered, resulting in an increase in the client's blood pressure. The solutions in option A, B, and C would not be given to this client because they are hypotonic solutions and, instead of increasing intravascular space, the solutions would move into the cells via osmosis.

24) C
- an infiltrated IV is one that has dislodged from the vein and is lying in subcutaneous tissue. When the pressure in the tissues exceeds the pressure in the tubing, the flow of the IV solution will stop. The corrective action is to remove the catheter and start a new IV line at another site. The other three options are likely to be accompanied by warmth at the site, not coolness.

25) A
- phlebitis at an IV site can be distinguished by client discomfort at the site and by redness, warmth, and swelling proximal to the catheter. If phlebitis occurs, the nurse should discontinue the IV line and insert a new IV line at a different site. Coolness at the site would be noted if the IV catheter was infiltrated. An allergic reaction produces a rash, redness, and itching. A major reaction, such as hypersensitivity, can cause dyspnea, a swollen tongue, and cyanosis.


PREVIOUS [---------------------] NEXT -> COGNITIVE ABILITY  26-30 --&gt


Related Topics:

• Fundamentals of Nursing  Concepts
• Medical-Surgical Concepts
• Maternal and Child Concepts

Read More

NCLEX Review about Cardiac Nursing (46-50)

NCLEX Review about Cardiac Nursing

46. The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if excess fluid volume is present?

a) weight loss
b) flat neck and hand veins
c) an increase in blood pressure
d) a decreased central venous pressure (CVP)

47. A nurse is caring for a client with acute congestive heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia were present?
. 46. The nurse is caring for a client with congestive heart failure. On assessment, the nurse notes that the client is dyspneic and that crackles are audible on auscultation. The nurse suspects excess fluid volume. What additional signs would the nurse expect to note in this client if excess fluid volume is present?

a) weight loss
b) flat neck and hand veins
c) an increase in blood pressure
d) a decreased central venous pressure (CVP)

47. A nurse is caring for a client with acute congestive heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia were present?

a) dry skin
b) decreased urinary output
c) hyperactive bowel sounds
d) increased specific gravity of the urine

48. A client arrives in the emergency room complaining of chest pain that began 4 hours ago. A troponin T blood specimen is obtained, and the results indicate a level of 0.6 ng/mL. The nurse interprets that this result indicates a:

a) normal level
b) low value that indicates possible gastritis
c) level that indicates a myocardial infarction
d) level that indicates the presence of possible angina

49. A client with atrial fibrillation who is receiving maintainance therapy of warfarin sodium (Coumadin) has a prothrombin time of 35 seconds. Based on the prothrombin time, the nurse anticipates which of the following orders?

a) adding a dose of heparin sodium
b) holding the next dose of warfarin
c) increasing the next dose of warfarin
d) administering the next dose of warfarin

50. A client recently diagnosed with a myocardial infarction and impaired renal function is recuperating on the step-down cardiac unit. The client's blood pressure has been borderline low and intravenous (IV) fluids have been infusing at 100 ml/hr via a central line catheter in the right internal jugular for approximately 24 hours to increase renal output and maintain blood pressure. on entering the client's room, the nurse notes that the client is breathing rapidly and is coughing. The nurse determines that hte client is most likely

a) hematoma
b) systemic infection
c) electrolyte overload
d) circulatory overload




NCLEX Review about Cardiac Nursing:
ANSWERS AND RATIONALE

46) C
- assessment findings associated with excess fluid volume include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure and a bounding pulse, an elevated CVP, weight gain, edema, neck and hand vein distention, altered level of consciousness, and a decreased hematocrit. Options A, B and D identify signs noted in deficient fluid volume.

47) C
- hyperactive bowel sounds indicate hyponatremia. Options A, B and D are signs of hypernatremia. In hyponatremia, increased urinary output and decreased specific gravity of the urinEdit Postse would be noted. Dry skin occurs in deficient fluid volume.

48) C
- troponin is a regulatory protein found in striated muscle. The troponins function together in the contractile apparatus for striated muscle in skeletal muscle and in the myocardium. Increased amounts of troponins T are released to the bloodstream when an infarction causes damage to the myocardium. A troponin T value that is higher than 0.1 to 0.2 ng/mL is consistent with a myocardial infarction.

49) B
- the normal prothrombin time (PT) is 9.6 to 11.8 seconds (male adult) or 9.5 to 11.3 seconds (female adult). A therapeutic PT level is 1.5 to 2.0 times higher than the normal level. Because the value of 35 seconds is high (and perhaps near the critical range), the nurse should anticipate that the client would not receive further doses at this time.

50) D
- circulatory (fluid overload) is a complication of intravenous therapy. Signs include rapid breathing, dyspnea, a moist cough, and crackles. When circulatory overload is present, the client's blood pressure would also increase. Hematoma is characterized by ecchymosis, swelling and leakage at the IV insertion site, and hard and painful lumps at the site. Systemic infection is characterized by chills, fever, malaise, headache, nausea, vomiting, backaches, and tachycardia. Signs of electrolyte imbalance depend on the specific electrolyte.



Go to the next page ---> NCLEX Review about Cardiac Nursing (51-55)  

Or go back to NCLEX Review about Cardiac Nursing (1-5) to start the test from the beginning.

Read More

NCLEX Secrets - Level of Cognitive Ability (Analysis 16-20)

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).


PREVIOUS [---------------------] NEXT -> COGNITIVE ABILITY  21-25 --&gt


Related Topics:

• Fundamentals of Nursing  Concepts
• Medical-Surgical Concepts
• Maternal and Child Concepts

Read More