A health care provider's prescription reads potassium chloride 20 mEq in 1000 mL normal
NCLEX Fundamentals II 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:
3.18.43 PM, Plus Cardio
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
NCLEX (137 Q&A) and Penicillin V 250 mg orally every 8 hours, is prescribed for a child with a respiratory infection.
Neurology NCLEX (328
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
Q&A). 100% Correct
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.
Answers 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: Strategy(ies): Subject
Focus on the subject, administration of theophylline, and note the word compliant. Priority Concepts: Clinical Judgment, Safety
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.
A child with leukemia is experiencing nausea related to medication therapy. The nurse,
Review: concerned about the child's nutritional status, should offer which during an episode of
Therapeutic range of theophylline. nausea?
Rationale:
When the child is nauseated, it is best to offer frequent intake of cool, clear liquids in small
The health care provider prescribes ibuprofen (children's Motrin) 5 mg per kg for a child who amounts because small portions are usually better tolerated. Cool, clear fluids are also
weighs 13 pounds. How many milligrams (mg) should the nurse administer to the child? Fill soothing and better tolerated when a client is nauseated. It is best not to offer favorite foods
in the blank. Record your answer using one decimal place. when the child is nauseated because foods eaten during times of nausea will be associated
Rationale: with being sick. It is best to offer small, frequent meals of high-protein and high-calorie
A child who weighs 13 pounds weighs 5.9 kg. This is determined by dividing 13 by 2.2 to content once the nausea has been controlled with medication or has subsided.
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
Level of Cognitive Ability: Applying Integrated Process: Nursing Process: Implementation
Client Needs: Physiological Integrity Content Area: Fundamental Skills: Nutrition
Integrated Process: Nursing Process: Implementation Strategy(ies): Subject
Content Area: Fundamental Skills: Medication/IV Calculations Priority Concepts: Cellular Regulation, Nutrition
Strategy(ies): Subject
Priority Concepts: Clinical Judgment, Safety
The nurse is caring for an older client who had a hip pinned after being fractured. In planning
Diphenhydramine hydrochloride (Benadryl) 25 mg orally every 6 hours is prescribed for a nursing care, which should the nurse avoid to minimize the chance for further injury?
child with an allergic reaction. The child weighs 25 kg. The safe pediatric dosage is 5 Rationale:
mg/kg/day. What should the nurse determine about the medication dosage? Safe nursing actions intended to prevent injury to the client include keeping side rails up,
Rationale: having the bed in a low position, and providing a call bell that is within the client's reach.
Calculate the dosage parameters using the safe dosage range identified in the question and Responding promptly to the client's use of the call light minimizes the chance that the client
the child's weight in kilograms. Next, determine the total daily dosage.Dosage parameters: 5 will try to get up alone, which could result in a fall.
mg/kg × 25 kg = 125 mg/dayDosage frequency: 25 mg × 4 doses = 100 mg/dayThe dosage
is safe. Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Level of Cognitive Ability: Analyzing Integrated Process: Nursing Process: Implementation
Client Needs: Physiological Integrity Content Area: Fundamental Skills: Safety
Integrated Process: Nursing Process: Data Collection Strategy(ies): Subject
Content Area: Fundamental Skills: Medication/IV Calculations Priority Concepts: Clinical Judgment, 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
A health care provider's prescription reads triazolam (Halcion), 125 mcg orally at bedtime metabolic acidosis. The nurse reviews the laboratory results and expects to note which?
daily. The medication bottle is labeled triazolam, 0.125-mg tablets. The nurse prepares how Rationale:
many tablet(s) to administer 1 dose? Fill in the blank. Signs/symptoms of metabolic acidosis include weakness, malaise, and headache.
Rationale: Hyperkalemia will occur because the cells will draw hydrogen into the cell and in exchange
Convert 125 mcg to mg. In the metric system, to convert smaller to larger, divide by 1000 or will push potassium out of the cell into the blood. The pH will be lower than 7.35, and the
move the decimal three places to the left. Therefore, 125 mcg = 0.125 mg. One tablet is HCO3– ion level will be lower than 22 mEq/L. The remaining options identify normal
administered. laboratory values, whereas a potassium level of 5.6 mEq/L indicates hyperkalemia.
Level of Cognitive Ability: Applying Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Planning Integrated Process: Nursing Process: Data Collection
Content Area: Fundamental Skills: Medication/IV Calculations Content Area: Fundamental Skills: Acid-Base
,Strategy(ies): Comparable or Alike Options
Priority Concepts: Clinical Judgment, Acid-Base Balance Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Implementation
A clear liquid diet has been prescribed for a client with gastroenteritis. Which item is Content Area: Fundamental Skills: Nutrition
appropriate to offer to the client? Strategy(ies): Comparable or Alike Options
Rationale: Priority Concepts: Health Promotion, Nutrition
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.
The health care provider prescribes a three-way bladder irrigation of normal saline to be
Level of Cognitive Ability: Applying infused at a rate of 200 mL per hour, which infused without problem. There is 1850 mL in the
Client Needs: Physiological Integrity collection receptacle at the conclusion of the 8-hour shift. Which is the client's true urine
Integrated Process: Nursing Process: Implementation output for the shift? Fill in the blank.
Content Area: Fundamental Skills: Nutrition Rationale:
Strategy(ies): Subject 200 mL × 8 hr = 1600, which is the amount of normal saline infused.
Priority Concepts: Inflammation, Nutrition 1850 - 1600 = 250 (total in receptacle minus irrigation)
Level of Cognitive Ability: Applying
The chart describes characteristics of various types of enemas. Which type of enema has the Client Needs: Physiological Integrity
highest risk of complications? Refer to chart. Integrated Process: Communication and Documentation
Content Area: Fundamental Skills: Elimination
View Chart Strategy(ies): Subject
Priority Concepts: Clinical Judgment, Elimination
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 The health care provider prescribes a three-way bladder irrigation of normal saline to be
saline enemas are the safest type of enema because of having the same osmotic pressure infused at a rate of 200 mL per hour, which infused without problem. There is 1850 mL in the
as fluid in the interstitial spaces around the bowel. Thus, enemas using normal saline do not collection receptacle at the conclusion of the 8-hour shift. Which is the client's true urine
cause any fluid shifts. Castile soap is incorrect because it can be mixed with either water or output for the shift? Fill in the blank.
saline, and if mixed with saline, there should not be any risk of fluid overload. Castile soap is Rationale:
the only safe soap to use for a soapsuds enema because harsh soaps may cause 200 mL × 8 hr = 1600, which is the amount of normal saline infused.
inflammation of the bowel. Hypertonic solution is incorrect because hypertonic fluids pull 1850 - 1600 = 250 (total in receptacle minus irrigation)
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 Level of Cognitive Ability: Applying
Fleets enema is the most common type of hypertonic enema. Client Needs: Physiological Integrity
Integrated Process: Communication and Documentation
Level of Cognitive Ability: Analyzing Content Area: Fundamental Skills: Elimination
Client Needs: Physiological Integrity Strategy(ies): Subject
Integrated Process: Nursing Process: Data Collection Priority Concepts: Clinical Judgment, Elimination
Content Area: Fundamental Skills: Elimination
Strategy(ies): Subject
Priority Concepts: Clinical Judgment, Elimination
The nurse is preparing a session regarding nutrition for a group of culturally diverse
pregnant women. The nurse determines that the priority nursing intervention includes
which action?
The nurse needs to increase the calcium in the diet of a client who is lactose intolerant. Rationale:
Which food items should the nurse encourage? Select all that apply. The priority nursing intervention is to identify the cultural food preferences of each client.
Rationale: This information is needed in order to adequately provide information regarding appropriate
Lactose-intolerant clients should not eat dairy products. Therefore, these clients need high- nutrition. The socioeconomic status may be an important component, particularly when the
calcium foods from nondairy sources. Tofu, broccoli, mustard greens, and sardines are foods nurse is determining whether a client's financial situation permits the purchase of
that are high in calcium that do not come from dairy sources. Although milk and cheese are appropriate food items. A baseline weight also may be important. Encouraging appropriate
high in calcium, they are dairy products, which lactose-intolerant clients need to avoid. nutrition and the need to avoid fast-food restaurants is also important. However, an
, adequate nutritional plan can be formulated only if cultural food preferences are identified.
Level of Cognitive Ability: Analyzing
Client Needs: Health Promotion and Maintenance The nurse determines that an adult male client admitted with dehydration and a hematocrit
Integrated Process: Teaching and Learning level of 56% has received adequate fluid volume replacement if which repeat hematocrit
Content Area: Fundamental Skills: Cultural Awareness level is noted?
Strategy(ies): Strategic Words Rationale:
Priority Concepts: Culture, Nutrition The normal hematocrit level for an adult male is 42% to 52%. Thus, 48% is the only correct
choice. The client who is dehydrated has an elevated level as a result of hemoconcentration.
The client's level may be expected to drift back down to within the normal range after the
fluid volume has been adequately restored. The remaining options are too high and indicate
fluid replacement is still indicated.
The health care provider's prescription reads "levothyroxine (Synthroid), 150 mcg orally
daily." The medication label reads "levothyroxine, 0.1 mg/tablet." The nurse prepares to
administer how many tablet(s) to the client? Fill in the blank. Record your answer using Level of Cognitive Ability: Evaluating
one decimal place. Client Needs: Physiological Integrity
Rationale: Integrated Process: Nursing Process: Evaluation
Convert 150 mcg to milligrams. In the metric system, to convert smaller to larger, divide by Content Area: Fundamental Skills: Laboratory Values
1000, or move the decimal three places to the left. Therefore, 150 mcg = 0.15 mg. Strategy(ies): Subject
Priority Concepts: Clinical Judgment, Fluid and Electrolyte Balance
Formula:
Desired × tablet(s)
A client with atrial fibrillation who is receiving maintenance therapy with warfarin sodium
––––––––––––––––––– = tablet(s) per dose
Available (Coumadin) has a prothrombin time (PT) of 30 seconds. The nurse anticipates that which will
be prescribed?
Rationale:
0.15 mg × 1 tablet The normal PT is 9.6 to 11.8 seconds for the adult male and 9.5 to 11.3 seconds for the adult
–––––––––––––––––– = 1.5 tablets
0.1 mg
female. The goal of oral anticoagulation with warfarin sodium therapy is to achieve a PT at
1.5 to 2 times the laboratory control value. A PT of 30 seconds places the client at risk for
bleeding, so the nurse should anticipate that the client would not receive further doses at
Level of Cognitive Ability: Applying this time. If the level is too high, the antidote (vitamin K) may be prescribed. The remaining
Client Needs: Physiological Integrity options would make the client even more prone to bleeding.
Integrated Process: Nursing Process: Planning
Content Area: Fundamental Skills: Medication/IV Calculations
Strategy(ies): Subject A client having preadmission testing before surgery has blood drawn for the determination
Priority Concepts: Clinical Judgment, Safety of serum electrolyte levels. The nurse determines that which result warrants a call to the
health care provider by the nurse?
Rationale:
The normal serum electrolyte ranges for adults are as follows: sodium, 135 to 145 mEq/L;
A licensed practical nurse (LPN) is asked to prepare an intravenous (IV) infusion of 1000 mL potassium, 3.5 to 5.0 mEq/L; chloride, 98 to 107 mEq/L; and bicarbonate (venous), 22 to 29
5% dextrose in lactated Ringer's at 80 mL/hr to be administered to an assigned client. The mEq/L. The only abnormal value identified is the serum sodium level.
LPN time-tapes the bag with a start time of 09:00. After making hourly marks on the time-
tape, the LPN notes that which time would mark the completion time for the bag?
Rationale:
At a rate of 80 mL per hour, the 1000-mL bag will be finished infusing in 12½ hours. This The nurse determines that sodium polystyrene sulfonate (Kayexalate) has been effective in
brings the end time to 21:30, using military time. a client if which laboratory result is noted?
Rationale:
Level of Cognitive Ability: Applying The normal serum potassium level in the adult is 3.5 to 5.0 mEq/L. Sodium polystyrene
Client Needs: Safe and Effective Care Environment (Kayexalate) is a medication that is used to treat hyperkalemia. The laboratory values in the
Integrated Process: Nursing Process: Implementation remaining options are slightly elevated; in addition, this medication would have no effect on
Content Area: Fundamental Skills: Medication/IV Calculations these other electrolytes.
Strategy(ies): Subject
Priority Concepts: Fluid and Electrolyte Balance, Safety
NCLEX Fundamentals II 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:
3.18.43 PM, Plus Cardio
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
NCLEX (137 Q&A) and Penicillin V 250 mg orally every 8 hours, is prescribed for a child with a respiratory infection.
Neurology NCLEX (328
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
Q&A). 100% Correct
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.
Answers 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: Strategy(ies): Subject
Focus on the subject, administration of theophylline, and note the word compliant. Priority Concepts: Clinical Judgment, Safety
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.
A child with leukemia is experiencing nausea related to medication therapy. The nurse,
Review: concerned about the child's nutritional status, should offer which during an episode of
Therapeutic range of theophylline. nausea?
Rationale:
When the child is nauseated, it is best to offer frequent intake of cool, clear liquids in small
The health care provider prescribes ibuprofen (children's Motrin) 5 mg per kg for a child who amounts because small portions are usually better tolerated. Cool, clear fluids are also
weighs 13 pounds. How many milligrams (mg) should the nurse administer to the child? Fill soothing and better tolerated when a client is nauseated. It is best not to offer favorite foods
in the blank. Record your answer using one decimal place. when the child is nauseated because foods eaten during times of nausea will be associated
Rationale: with being sick. It is best to offer small, frequent meals of high-protein and high-calorie
A child who weighs 13 pounds weighs 5.9 kg. This is determined by dividing 13 by 2.2 to content once the nausea has been controlled with medication or has subsided.
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
Level of Cognitive Ability: Applying Integrated Process: Nursing Process: Implementation
Client Needs: Physiological Integrity Content Area: Fundamental Skills: Nutrition
Integrated Process: Nursing Process: Implementation Strategy(ies): Subject
Content Area: Fundamental Skills: Medication/IV Calculations Priority Concepts: Cellular Regulation, Nutrition
Strategy(ies): Subject
Priority Concepts: Clinical Judgment, Safety
The nurse is caring for an older client who had a hip pinned after being fractured. In planning
Diphenhydramine hydrochloride (Benadryl) 25 mg orally every 6 hours is prescribed for a nursing care, which should the nurse avoid to minimize the chance for further injury?
child with an allergic reaction. The child weighs 25 kg. The safe pediatric dosage is 5 Rationale:
mg/kg/day. What should the nurse determine about the medication dosage? Safe nursing actions intended to prevent injury to the client include keeping side rails up,
Rationale: having the bed in a low position, and providing a call bell that is within the client's reach.
Calculate the dosage parameters using the safe dosage range identified in the question and Responding promptly to the client's use of the call light minimizes the chance that the client
the child's weight in kilograms. Next, determine the total daily dosage.Dosage parameters: 5 will try to get up alone, which could result in a fall.
mg/kg × 25 kg = 125 mg/dayDosage frequency: 25 mg × 4 doses = 100 mg/dayThe dosage
is safe. Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Level of Cognitive Ability: Analyzing Integrated Process: Nursing Process: Implementation
Client Needs: Physiological Integrity Content Area: Fundamental Skills: Safety
Integrated Process: Nursing Process: Data Collection Strategy(ies): Subject
Content Area: Fundamental Skills: Medication/IV Calculations Priority Concepts: Clinical Judgment, 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
A health care provider's prescription reads triazolam (Halcion), 125 mcg orally at bedtime metabolic acidosis. The nurse reviews the laboratory results and expects to note which?
daily. The medication bottle is labeled triazolam, 0.125-mg tablets. The nurse prepares how Rationale:
many tablet(s) to administer 1 dose? Fill in the blank. Signs/symptoms of metabolic acidosis include weakness, malaise, and headache.
Rationale: Hyperkalemia will occur because the cells will draw hydrogen into the cell and in exchange
Convert 125 mcg to mg. In the metric system, to convert smaller to larger, divide by 1000 or will push potassium out of the cell into the blood. The pH will be lower than 7.35, and the
move the decimal three places to the left. Therefore, 125 mcg = 0.125 mg. One tablet is HCO3– ion level will be lower than 22 mEq/L. The remaining options identify normal
administered. laboratory values, whereas a potassium level of 5.6 mEq/L indicates hyperkalemia.
Level of Cognitive Ability: Applying Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Planning Integrated Process: Nursing Process: Data Collection
Content Area: Fundamental Skills: Medication/IV Calculations Content Area: Fundamental Skills: Acid-Base
,Strategy(ies): Comparable or Alike Options
Priority Concepts: Clinical Judgment, Acid-Base Balance Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process: Implementation
A clear liquid diet has been prescribed for a client with gastroenteritis. Which item is Content Area: Fundamental Skills: Nutrition
appropriate to offer to the client? Strategy(ies): Comparable or Alike Options
Rationale: Priority Concepts: Health Promotion, Nutrition
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.
The health care provider prescribes a three-way bladder irrigation of normal saline to be
Level of Cognitive Ability: Applying infused at a rate of 200 mL per hour, which infused without problem. There is 1850 mL in the
Client Needs: Physiological Integrity collection receptacle at the conclusion of the 8-hour shift. Which is the client's true urine
Integrated Process: Nursing Process: Implementation output for the shift? Fill in the blank.
Content Area: Fundamental Skills: Nutrition Rationale:
Strategy(ies): Subject 200 mL × 8 hr = 1600, which is the amount of normal saline infused.
Priority Concepts: Inflammation, Nutrition 1850 - 1600 = 250 (total in receptacle minus irrigation)
Level of Cognitive Ability: Applying
The chart describes characteristics of various types of enemas. Which type of enema has the Client Needs: Physiological Integrity
highest risk of complications? Refer to chart. Integrated Process: Communication and Documentation
Content Area: Fundamental Skills: Elimination
View Chart Strategy(ies): Subject
Priority Concepts: Clinical Judgment, Elimination
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 The health care provider prescribes a three-way bladder irrigation of normal saline to be
saline enemas are the safest type of enema because of having the same osmotic pressure infused at a rate of 200 mL per hour, which infused without problem. There is 1850 mL in the
as fluid in the interstitial spaces around the bowel. Thus, enemas using normal saline do not collection receptacle at the conclusion of the 8-hour shift. Which is the client's true urine
cause any fluid shifts. Castile soap is incorrect because it can be mixed with either water or output for the shift? Fill in the blank.
saline, and if mixed with saline, there should not be any risk of fluid overload. Castile soap is Rationale:
the only safe soap to use for a soapsuds enema because harsh soaps may cause 200 mL × 8 hr = 1600, which is the amount of normal saline infused.
inflammation of the bowel. Hypertonic solution is incorrect because hypertonic fluids pull 1850 - 1600 = 250 (total in receptacle minus irrigation)
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 Level of Cognitive Ability: Applying
Fleets enema is the most common type of hypertonic enema. Client Needs: Physiological Integrity
Integrated Process: Communication and Documentation
Level of Cognitive Ability: Analyzing Content Area: Fundamental Skills: Elimination
Client Needs: Physiological Integrity Strategy(ies): Subject
Integrated Process: Nursing Process: Data Collection Priority Concepts: Clinical Judgment, Elimination
Content Area: Fundamental Skills: Elimination
Strategy(ies): Subject
Priority Concepts: Clinical Judgment, Elimination
The nurse is preparing a session regarding nutrition for a group of culturally diverse
pregnant women. The nurse determines that the priority nursing intervention includes
which action?
The nurse needs to increase the calcium in the diet of a client who is lactose intolerant. Rationale:
Which food items should the nurse encourage? Select all that apply. The priority nursing intervention is to identify the cultural food preferences of each client.
Rationale: This information is needed in order to adequately provide information regarding appropriate
Lactose-intolerant clients should not eat dairy products. Therefore, these clients need high- nutrition. The socioeconomic status may be an important component, particularly when the
calcium foods from nondairy sources. Tofu, broccoli, mustard greens, and sardines are foods nurse is determining whether a client's financial situation permits the purchase of
that are high in calcium that do not come from dairy sources. Although milk and cheese are appropriate food items. A baseline weight also may be important. Encouraging appropriate
high in calcium, they are dairy products, which lactose-intolerant clients need to avoid. nutrition and the need to avoid fast-food restaurants is also important. However, an
, adequate nutritional plan can be formulated only if cultural food preferences are identified.
Level of Cognitive Ability: Analyzing
Client Needs: Health Promotion and Maintenance The nurse determines that an adult male client admitted with dehydration and a hematocrit
Integrated Process: Teaching and Learning level of 56% has received adequate fluid volume replacement if which repeat hematocrit
Content Area: Fundamental Skills: Cultural Awareness level is noted?
Strategy(ies): Strategic Words Rationale:
Priority Concepts: Culture, Nutrition The normal hematocrit level for an adult male is 42% to 52%. Thus, 48% is the only correct
choice. The client who is dehydrated has an elevated level as a result of hemoconcentration.
The client's level may be expected to drift back down to within the normal range after the
fluid volume has been adequately restored. The remaining options are too high and indicate
fluid replacement is still indicated.
The health care provider's prescription reads "levothyroxine (Synthroid), 150 mcg orally
daily." The medication label reads "levothyroxine, 0.1 mg/tablet." The nurse prepares to
administer how many tablet(s) to the client? Fill in the blank. Record your answer using Level of Cognitive Ability: Evaluating
one decimal place. Client Needs: Physiological Integrity
Rationale: Integrated Process: Nursing Process: Evaluation
Convert 150 mcg to milligrams. In the metric system, to convert smaller to larger, divide by Content Area: Fundamental Skills: Laboratory Values
1000, or move the decimal three places to the left. Therefore, 150 mcg = 0.15 mg. Strategy(ies): Subject
Priority Concepts: Clinical Judgment, Fluid and Electrolyte Balance
Formula:
Desired × tablet(s)
A client with atrial fibrillation who is receiving maintenance therapy with warfarin sodium
––––––––––––––––––– = tablet(s) per dose
Available (Coumadin) has a prothrombin time (PT) of 30 seconds. The nurse anticipates that which will
be prescribed?
Rationale:
0.15 mg × 1 tablet The normal PT is 9.6 to 11.8 seconds for the adult male and 9.5 to 11.3 seconds for the adult
–––––––––––––––––– = 1.5 tablets
0.1 mg
female. The goal of oral anticoagulation with warfarin sodium therapy is to achieve a PT at
1.5 to 2 times the laboratory control value. A PT of 30 seconds places the client at risk for
bleeding, so the nurse should anticipate that the client would not receive further doses at
Level of Cognitive Ability: Applying this time. If the level is too high, the antidote (vitamin K) may be prescribed. The remaining
Client Needs: Physiological Integrity options would make the client even more prone to bleeding.
Integrated Process: Nursing Process: Planning
Content Area: Fundamental Skills: Medication/IV Calculations
Strategy(ies): Subject A client having preadmission testing before surgery has blood drawn for the determination
Priority Concepts: Clinical Judgment, Safety of serum electrolyte levels. The nurse determines that which result warrants a call to the
health care provider by the nurse?
Rationale:
The normal serum electrolyte ranges for adults are as follows: sodium, 135 to 145 mEq/L;
A licensed practical nurse (LPN) is asked to prepare an intravenous (IV) infusion of 1000 mL potassium, 3.5 to 5.0 mEq/L; chloride, 98 to 107 mEq/L; and bicarbonate (venous), 22 to 29
5% dextrose in lactated Ringer's at 80 mL/hr to be administered to an assigned client. The mEq/L. The only abnormal value identified is the serum sodium level.
LPN time-tapes the bag with a start time of 09:00. After making hourly marks on the time-
tape, the LPN notes that which time would mark the completion time for the bag?
Rationale:
At a rate of 80 mL per hour, the 1000-mL bag will be finished infusing in 12½ hours. This The nurse determines that sodium polystyrene sulfonate (Kayexalate) has been effective in
brings the end time to 21:30, using military time. a client if which laboratory result is noted?
Rationale:
Level of Cognitive Ability: Applying The normal serum potassium level in the adult is 3.5 to 5.0 mEq/L. Sodium polystyrene
Client Needs: Safe and Effective Care Environment (Kayexalate) is a medication that is used to treat hyperkalemia. The laboratory values in the
Integrated Process: Nursing Process: Implementation remaining options are slightly elevated; in addition, this medication would have no effect on
Content Area: Fundamental Skills: Medication/IV Calculations these other electrolytes.
Strategy(ies): Subject
Priority Concepts: Fluid and Electrolyte Balance, Safety
