NCLEX Questions, NCLEX PN Test Questions with NGN Questions, NCLEX-PN Questions, Nurselytic

Correct Answer: C,B

Rationale: Heart failure (HF) is a chronic, progressive condition characterized by impaired ventricular function that leads to decreased cardiac output and
causes blood to back up into the lungs and systemic circulation. This results in fluid volume overload that is commonly treated with diuretics,
such as furosemide (ie, "water pill"), that remove excess fluid through increased urination.
A client with HF who is experiencing dyspnea, inspiratory crackles, weight gain, and peripheral edema is demonstrating fluid volume overload
from a probable acute HF exacerbation. The nurse should immediately follow up on potentially life-threatening findings such as the client's:
• Blood pressure, which is moderately elevated and requires urgent intervention with medications (eg, diuretics). Fluid overload causes
increased pressure in the blood vessels, leading to hypertension that increases afterload. This is especially concerning for HF because
the heart muscle is already weak and cannot withstand additional afterload.
• Respiratory findings (ie, capillary oxygen saturation [SpOz) 90% on room air, inspiratory crackles, tachypnea, dyspnea, labored
respirations) because these likely indicate pulmonary edema. Crackles are a manifestation of pulmonary edema caused by fluid in the
alveoli that leads to impaired gas exchange and hypoxemia.
(Incorrect) Weiaht aain and lower extremity edema are also indicators of fluid volume overload however these findinas are not directly life

Correct Answer:

Rationale: Expected prescriptions for clients with suspected infective endocarditis (IE) include:
• Administering IV antibiotics to kill the infectious pathogen
• Preparing the client for echocardiography to identify valvular dysfunction, chamber enlargement, and vegetations
• Placing a peripherally inserted central catheter for long-term IV antibiotic therapy
• Collecting a blood specimen for culture and sensitivity to identify the infectious pathogen
Initiating low-flow supplemental oxygen is not expected because the client is not exhibiting signs of respiratory distress.
Pericardiocentesis is performed to remove excess fluid from the pericardial cavity and prevent progression to cardiac
tamponade. Pericardial effusions are not commonly expected with IE. Furthermore, this client is not exhibiting signs of
pericardial effusion (eg, muffled heart sounds, substernal pain).
Therefore, gathering supplies for pericardiocentesis is not
expected.

Correct Answer: A

Rationale: Aripiprazole, an atypical antipsychotic medication, is used in the treatment of irritability associated with autism spectrum
disorder (AS
D), schizophrenia, bipolar disorder, and other mental health disorders. Aripiprazole works as a partial agonist at
the serotonin and dopamine receptor sites. As a result, the medication has a more favorable safety profile (eg, fewer metabolic
effects, lower potential for prolactin release) than other antipsychotics; however, it may be less effective in symptom relief.
Clients taking aripiprazole should be reminded to not abruptly stop taking the medication because it can cause withdrawal
symptoms (eg, anxiety, dizziness, tachycardia, diaphoresis, insomnia, vomiting) and may exacerbate previous symptoms.
These medications should be weaned over time and substituted with an alternate medication under the supervision of a health
care provider

Correct Answer:

Rationale: Heart failure (F) exacerbation management focuses on improving oxygenation and reducing fluid overload. Expected
prescriptions include:
• Performing daily weights to monitor fluid volume status and guide treatment. Ideally, daily weights should be performed
at the same time of day, on the same scale, and with the client wearing the same amount/type of clothes. Rapid weight
gain (ie, >5 lb/week [(2.3 kg/week]) should be communicated to the health care provider immediately.
• Administering loop diuretics (eg, furosemide, torsemide, bumetanide) to prevent reabsorption of sodium and chloride in
the kidneys, which increases fluid excretion and urine output. This provides symptom relief by reducing pulmonary
congestion and peripheral edema.
• Applying compression stockings, a common nopharmacological intervention, to promote venous blood return and
reduce peripheral edema.
Limiting mobility is unexpected for a client with increased fluid volume. The client should be encouraged to ambulate
frequently to promote venous return, exercise cardiac muscle, and reduce risk of deep venous thrombosis.
Increasing oral fluid intake is unexpected for a client with hypervolemia (ie, heart failure exacerbation) because it
exacerbates existing symptoms (eg, edema, pulmonary congestion).

Correct Answer: A,B

Rationale: The client's laboratory results show hyperkalemia (ie, high potassium) and decreased kidney function, seen as elevated BUN and creatinine.
The kidneys balance potassium levels by eliminating excess potassium through urine. Clients with heart failure (HF) are at an increased risk fo
hyperkalemia due to poor kidney perfusion from decreased cardiac output and medication adverse effects. This client's decreased kidney
function and home medications, including lisinopril (ACE inhibitor) and supplemental potassium chloride, all increase the risk of hyperkalemia.
Because potassium is responsible for myocardial cell repolarization, hyper- or hypokalemia may lead to life-threatening dysrhythmias.

Therefore, the nurse should prioritize interventions to treat hyperkalemia due to the risk of dysrhythmias.