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

Correct Answer:

Rationale: Appropriate interventions for the client with major depressive disorder who is experiencing suicidal ideation include the
following:
• Assigning the client to a shared room near the nurses' station to reduce social isolation and allow easier access to the
client
• Avoiding utensils on the client's meal tray that could be used for self-harm
• Checking on the client at frequent, irregular intervals (if not under 1-to-1 observation) to lessen predictability of staff
surveillance
• Performing frequent room searches for harmful objects to ensure client safety
• Performing mouth checks after medication administration to ensure the client has swallowed medication and is not
saving them for a future overdose attempt
• Encouraging the client to participate in grooming and hygiene because the client may exhibit loss of interest in daily
activities, decreased energy, and lack of motivation
Avoiding discussion of suicidal thoughts is not appropriate. Clients with suicidal ideation are often reluctant to disclose
their thoughts unless asked directly. The nurse should establish a nonjudgmental, therapeutic relationship that allows for open
communication.
It is not appropriate for the nurse to document that the client is not available for a safety check when the client is using the
restroom. The nurse must ensure that there is visual contact with the client during safety checks, even if the client is in the
restroom, to ensure safety.

Correct Answer: A

Rationale: Treatment for hyperkalemia includes administration of calcium gluconate, furosemide, albuterol nebulizer, and insulin with dextrose. These
therapies may cause rapid shifts in fluid volume, blood glucose, and serum electrolytes. Insulin shifts available glucose and potassium into
the cell, lowering serum potassium levels; however, too much insulin and not enough dextrose cause hypoglycemia (eg, blood glucose 50
mg/dL [2.7 mmol/L]). Clients with kidney disease have an increased risk of hypoglycemia because insulin may accumulate.
The nurse should understand that a low blood glucose level and symptoms suspicious for hypoglycemia (eg, diaphoresis) require follow-u
to prevent seizures, coma, and death due to lack of circulating glucose (Option 1). This client requires an additional dose of dextrose.
(Option 2) This client's blood pressure is 146/88 mm Hg and heart rate is within normal limits. This is an improvement from the initial blood
pressure and represents a therapeutic response to furosemide administration. Blood pressure should be lowered slowly to avoid hypotensior

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.

Correct Answer: A,B,C,D,F

Rationale: The nurse should immediately follow up on the following findings:
• Hypoxemia (eg, SpO, 92% on 100% oxygen [nonrebreather mask]) indicates an abnormality with ventilation and/or perfusion.
• Unilateral chest wall expansion on inspiration indicates one side of the lung is not inflating. This is usually due to lung collapse,
which could be due to an internal airway dysfunction (eg, mucous plug blocking air entry) or external compression (eg, pneumothorax).
• Tracheal deviation (ie, displacement of the trachea to one side) occurs when pressure from one side of the chest is higher than the
other, pushing the mediastinal structures to the side with less pressure. This is usually due to a large hemothorax or pneumothorax.
• Diminished breath sounds indicate the lung is not adequately expanding (eg, atelectasis, pneumothorax).
• Hypotension (eg, BP 90/58 mm Hg) occurs from several mechanisms, including compression of the heart (eg, cardiac tamponade)
and/or great vessels (eg, tension pneumothorax), inadequate ventricular filling between heartbeats (eg, supraventricular tachycardia),
volume depletion, and other conditions

Correct Answer:

Rationale: When a client with diabetes mellitus experiences an infection or another illness, the release of stress hormones can cause increased insulin
resistance, which increases the blood glucose level and leads the body to break down fats for energy (ketosis). This can precipitate diabeti
ketoacidosis (DK
A) as break down of fatty acids produces ketones. Interventions for managing diabetes mellitus and preventing DKA durin
an illness include:
• Increasing fluid intake to help clear ketones from the system and prevent dehydration during illness
• Checking blood glucose levels more frequently (eg, every 4 hr) to monitor for hyperglycemia
• Monitoring the urine for ketones if blood glucose levels are persistently elevated (>240 mg/dL [13.3 mmol/L]) for early detection of
impending DKA
• Consuming beverages that contain glucose and replacing electrolytes if nausea and vomiting are present
• Notifying the health care provider of persistently elevated blood glucose levels, ketones in the urine, high fever, nausea, vomiting, or
diarrhea