NCLEX - PN Questions And Answers Reviewed Latest Updated Exam

NCLEX - PN Questions And Answers 2024 Reviewed Latest Updated Exam

1. A nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L.The nurse understands that a potassium value at this level would be noted with which condition: Traumatic burn Rationale: A serum potassium level that exceeds 5.1 mEq/L is indicative of hyperkalemia. Clients who experience the cellular shifting of potassium, as in the early stages of massive cell destruction (i.e., with trauma, burns, sepsis, or metabolic or respiratory acidosis), are at risk for hyperkalemia. The client with Cushing's syndrome or diarrhea and the client who has been overusing laxatives are at risk for hypokalemia. 2. A nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L.Which of the following would the nurse note on the cardiac monitor as a result of this laboratory value?: Narrow, peaked T waves Rationale: A serum potassium level of 5.4 mEq/L is indicative of hyperkalemia. Cardiac changes include a wide, flat P wave; a prolonged PR interval; a widened QRS complex; narrow, peaked T waves; and a depressed ST segment. 3. A nurse is reviewing the health records of assigned clients.The nurse plans care knowing that which client is at the lowest risk for the development of third-spacing?: The client with diabetes mellitus Fluid that shifts into the interstitial spaces and remains there is referred to as thirdspace fluid. Common sites for third-spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Risk factors include liver or kidney disease, major trauma, burns, sepsis, wound healing, major surgery, malignancy, malabsorption syndrome, malnutrition, alcoholism, and older age. 4. A nurse is reviewing the health records of assigned clients.The nurse plans care knowing that which client is at risk for fluid volume deficit?: The client with a colostomy Rationale: Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid 2 / 27 replacement, draining fistulas, ileostomy, and colostomy.A client with cirrhosis, CHF, or decreased kidney function is at risk for fluid volume excess. 5. A nurse reviews electrolyte values and notes a sodium level of 130 mEq/L. The nurse understands that this sodium level would be noted in a client with which condition?: The client with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) Rationale: Hyponatremia is a serum sodium level less than 135 mEq/L. Hyponatremia can result secondary to SIADH.The client with an inadequate daily water intake, watery diarrhea, or diabetes insipidus is at risk for hypernatremia. 6. A nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins.The nurse suspects hyponatremia. What additional signs would the nurse expect to note in this client if hyponatremia is present?: Postural blood pressure changes Rationale: Postural blood pressure changes occur in the client with hyponatremia. Dry mucous membranes and intense thirst are seen in clients with hypernatremia. A slow, bounding pulse is not indicative of hyponatremia. In a client with hyponatremia, a rapid thready pulse is noted. 7. A nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which of the following signs would be an indication of this diagnosis: Generalized muscle weakness Rationale: Generalized muscle weakness is seen in clients with hypercalcemia. Options 1,twitching 2, Positive Trousseau's sign and 3 Hyperactive bowel sounds identify signs of hypocalcemia. 8. A nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL. Which medication should the nurse prepare to administer as prescribed to the client?: Calcitonin (Miacalcin) Rationale: The normal serum calcium level is 8.6 to 10.0 mg/dL. This client is experiencing hypercalcemia. Calcium gluconate and calcium chloride are medications used for the treatment of tetany, which occurs as a result of acute hypocalcemia. In hypercalcemia, large doses of vitamin D need to be avoided. Calcitonin, a thyroid hormone, decreases the plasma calcium level by inhibiting bone resorption and lowering the serum calcium concentration.