NCLEX RN Questions for Health Promotion and Maintenance

1.    Nurse Tristan is assigned to care for a group of clients. On review of the clients’ medical records, the nurse determines that which client is at risk for deficient fluid volume?
a.    A client with a colostomy
b.    A client with congestive heart failure
c.    A client with decreased kidney function
d.    A client receiving frequent wound irrigation

2.    Nurse Lorena caring for a client who has been receiving intravenous diuretics suspects that the client is experiencing a deficient fluid volume. Which assessment finding would the nurse note in a client with this condition?
a.    Lung congestion
b.    Decrease hematocrit
c.    Increased blood pressure
d.    Decrease central venous pressure (CVP)

3.    Nurse George is assigned to care for a group of clients. On review of the clients’ medical records, the nurse determines that which client is at risk for excess fluid volume?
a.    The client taking diuretics
b.    The client with renal failure
c.    The client with an ileostomy
d.    The client who requires gastrointestinal suctioning

4.    Nurse Levy 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)

5.    Nurse Faye is preparing to care for a client with a potassium deficit. The nurse reviews the client was at risk for developing the potassium deficit because the client:
a.    Has renal failure
b.    Requires nasogastric suction
c.    Has a history of Addison’s disease
d.    Is taking a potassium-sparing diuretic

6.    Nurse Jessica reviews a client’s electrolyte laboratory report and notes that the potassium level is 3.2 mEq/L. which of the following would the nurse note on the electrocardiogram as a result of the laboratory value?
a.    U waves
b.    Absent P waves
c.    Elevated T waves
d.    Elevated ST segment

7.    Tanya, a nursing student needs to administer potassium chloride intravenously as prescribed to a client with hypokalemia. The nursing instructor determines that the student is unprepared for this procedure if the student states that which of the following is part of the plan for preparation and administration of the potassium?
a.    Obtaining a cotrolled IV infusion pump
b.    Monitoring urine output during administration
c.    Diluting in appropriate amount of normal saline
d.    Preparing the medication for bolus administration

8.    Nurse Kim caring for a group of clients reviews the electrolyte laboratory results and notes a potassium level og 5.5 mEq/L on one client’s laboratory report. The nurse understands that which client is at highest risk for the development of a potassium value at this level?
a.    The client with colitis
b.    The client with Cushing’s syndrome
c.    The client who has been overusing laxatives
d.    The client who has sustained a traumatic burn

9.    Nurse Nerissa reviews the electrolyte results of an assigned client and notes that the potassium level is 5.4 mEq/L. which of the following would the nurse expect to note on the electrocardiogram as a result of the laboratory value?
a.    ST depression
b.    Inverted T wave
c.    Prominent U wave
d.    Tall peaked T waves

10.    Nurse Noemi caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client’s laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level?
a.    The client with renal failure
b.    The client who is taking diuretics
c.    The client with hyperaldosteronism
d.    The client who is taking corticosteroids

11.    Nurse Princess 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 muscles 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.    Decrease urinary output
c.    Hyperactive bowel sounds
d.    Increased specific gravity of the urine

12.    Nurse Andrew is reviewing a client’s laboratory report and notes that the serum calcium level is 4.0 mg/dL. The nurse understands that which condition most likely caused this serum calcium level?
a.    Prolonged bed rest
b.    Renal insufficiency
c.    Hyperparathyroidism
d.    Excessive ingestion of vitamin D

13.    Nurse Editha is assessing a client with a suspected diagnosis of hypocalcemia. Which of the following clinical manifestations would the nurse expect to note in the client?
a.    Twitching
b.    Negative Trousseau’s sign
c.    Hypoactive bowel sounds
d.    Hypoactive deep tendon reflexes

14.    Nurse Sally caring for a client with hypocalcemia would expect to note which of the following changes on the electrocardiogram?
a.    Widened T wave
b.    Prominent U wave
c.    Prolonged QT interval
d.    Shortened ST segment

15.    Nurse Sam caring for a client with severe malnutrition reviews the laboratory results and notes a magnesium level of 1.0 mg/dL. Which electrocardiographic changes would the nurse expects to note based on the magnesium level?
a.    Prominent U waves
b.    Prolonged PR interval
c.    Depressed ST segment
d.    Widened QRS complexes

16.    Nurse Danny reviews a client’s laboratory report and notes that the client’s serum phosphorus level is 2.0 mg/dL. Which condition most likely caused this serum phosphorus level?
a.    Alcoholism
b.    Renal insufficiency
c.    Hypoparathyroidism
d.    Tumor lysis syndrome

17.    A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rete of 6 breaths/min. The electrocardiogram (ECG) monitor displays tachycardia, with a heart rate of 120 beats/min. Arterial blood gases are drawn and nurse Gio reviews the results, expecting to note which of the following?
a.    A decreased pH and an increased CO2
b.    An increased pH and a decreased CO2
c.    A decreased pH and a decreased HCO3
d.    An increased pH with an increased HCO3

18.    Nurse Venus is assigned to a 40-year-old client who has a diagnosis of chronic pancreatitis. The nurse reviews the laboratory result, anticipating a laboratory report that indicating a laboratory report that indicates a serum amylase level of:
a.    45 units/L
b.    100 units/L
c.    300 units/L
d.    500 units/L

19.    A client has been admitted to the hospital for urinary tract infection and dehydration. Nurse Veronica determines that the client has received adequate volume replacement if the blood urea nitrogen level drops to:
a.    3 mg/dL
b.    15 mg/dL
c.    29 mg/dL
d.    35 mg/dL

20.    A maleclient 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. Nurse Celeste interprets that this result indicates a:
a.    Normal level
b.    Low value that indicates possible gastritis
c.    Level that indicates a myocardial infraction
d.    Level that indicates the presence of possible angina

21.    An adult client has had laboratory work done as part of a routine physical examination. Nurse Amy interprets that the client may have a mild degree of renal insufficiency if which of the following serum creatinine levels is noted?
a.    0.2 mg/dL
b.    0.5 mg/dL
c.    1.9 mg/dL
d.    3.5 mg/dl

22.    A female client with atrial fibrillation who is receiving maintenance therapy of warfarin sodium (Coumadin) has a prothrombin time of 35 seconds. Based on the prothrombin time, nurse Daniel 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

23.    A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client’s activated partial thromboplastin (aPTT) time is 65 seconds. Nurse Jessie anticipates that which action is needed?
a.    Discontinuing the heparin infusion
b.    Increasing the rate of the heparin infusion
c.    Decreasing the rate of the heparin infusion
d.    Leaving the rate of the heparin infusion as is

24.    An adult client was diagnosed with acute pancreatitis 9 days ago. The nurse interprets that the client is recovering from this episode if the serum lipase level decreases to which of the following values, which is just below the upper limit of normal?
a.    20 units/L
b.    80 units/L
c.    135 units/L
d.    350 units/L

25.    An adult female has a hemoglobin level of 10.8 g/dL. Nurse Gemma 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

 

Answers and Rationale

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