Questions 151

NCLEX-RN

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Question 1 of 5

A client with acute pancreatitis is put on nothing-by-mouth status, with the intent of not stimulating the pancreas. The client is prescribed an I.V. infusion of dextrose 5% in half-normal saline solution at 120 mL/hour. After 3 days of this regimen, the nurse should observe the client for which of the following metabolic conditions?

Correct Answer: B

Rationale: Dextrose 5% infusion can lead to hyperglycemia, especially in a client with acute pancreatitis, requiring monitoring.

Question 2 of 5

The nurse is teaching a client with gout about dietary management. Which of the following foods should the client avoid?

Correct Answer: C

Rationale: Organ meats are high in purines, which increase uric acid levels and should be avoided in gout.

Question 3 of 5

Which of the following techniques is correct when administering a subcutaneous injection?

Correct Answer: B

Rationale: A subcutaneous injection is correctly administered at a 45-degree angle (or 90 degrees for obese patients) using a 5/8-inch needle, pinching the skin, without an air bubble.

Question 4 of 5

An adolescent with type 1 diabetes mellitus is hospitalized for appendicitis. He is weak and nauseated with poor skin turgor. The nurse notes a fruity odor to the client's breath. The client uses insulin. The nurse should suspect:

Correct Answer: A

Rationale: Fruity breath, weakness, nausea, and poor skin turgor in a type 1 diabetic suggest diabetic ketoacidosis, a complication of uncontrolled hyperglycemia. Hypoglycemia would present with shakiness or sweating, not fruity breath.

Question 5 of 5

Select the basic sterile asepsis procedures that are accurate. Select all that apply:

Correct Answer: A,C,E

Rationale: Sterile items only on the sterile field , coughing/sneezing contaminating the field , and moisture contaminating the field are accurate sterile asepsis principles. The sterile field must be above waist level (B is incorrect), a 1-inch border is standard (D is incorrect), and masks are not required for clients (F is incorrect).

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