Questions 9

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Nursing Process NCLEX Questions Questions

Question 1 of 5

A client's IV fluid orders for 24 hour's are 1500 ml D5W followed by 1250 ml of NS. The IV tubing has a drop factor of 15 gtt/ml. To administer the required fluids the nurse should set the drip rate at;

Correct Answer: B

Rationale: To calculate the drip rate, we first need to find the total volume of IV fluid to be administered, which is 1500 ml + 1250 ml = 2750 ml. Then, we multiply the total volume by the drop factor (2750 ml * 15 gtt/ml = 41250 gtt). Finally, we divide the total number of drops by the time in minutes (24 hours * 60 min = 1440 min) to get the drip rate: 41250 gtt / 1440 min = 28.47 gtt/min, which rounds up to 29 gtt/min. Therefore, choice B is correct. Choices A, C, and D are incorrect because they do not reflect the accurate calculation based on the given parameters.

Question 2 of 5

When preparing a site for venipunctures with alcohol, how long must the area be cleaned?

Correct Answer: D

Rationale: The correct answer is D: 60 seconds. This is because the area must be cleaned for at least 60 seconds to effectively disinfect the skin and reduce the risk of infection during venipuncture. Cleaning for shorter durations (5, 10, or 30 seconds) may not be sufficient to achieve proper disinfection. Thoroughly cleaning the area for a full minute ensures that the alcohol has enough time to kill bacteria and pathogens on the skin, making it safer for the venipuncture procedure. Shorter cleaning times may leave pathogens behind, increasing the risk of contamination and infection.

Question 3 of 5

A client with anemia has been admitted to the medical-surgical unit. Which assessment findings are characteristic of iron-deficiency anemia?

Correct Answer: C

Rationale: Rationale: 1. Anemia results in decreased oxygen-carrying capacity, leading to tissue hypoxia. 2. Dyspnea (shortness of breath) occurs due to the body's attempt to increase oxygen intake. 3. Tachycardia (rapid heart rate) compensates for decreased oxygen delivery. 4. Pallor (pale skin) is a classic sign of decreased red blood cells in iron-deficiency anemia. Summary: A: Night sweats, weight loss, and diarrhea are not typical manifestations of iron-deficiency anemia. B: Nausea, vomiting, and anorexia are non-specific symptoms and not specific to iron-deficiency anemia. D: Itching, rash, and jaundice are not commonly associated with iron-deficiency anemia.

Question 4 of 5

A nurse is assigned to care for a client diagnosed with asthma who has just been admitted to the health care facility. The nurse determines the client’s priorities for care using which of the following?

Correct Answer: A

Rationale: The correct answer is A, assessment skills. Assessing the client's current condition, including respiratory status, is crucial in determining priorities for care in asthma management. By utilizing assessment skills, the nurse can gather essential information to identify the client's immediate needs and develop an individualized care plan. Nursing books (B) can provide general information but do not provide real-time data on the client's current status. Client's records (C) may contain historical information but may not reflect the client's current condition. Supervisor's advice (D) is important but should supplement rather than replace the nurse's assessment skills in determining immediate care priorities.

Question 5 of 5

A few hours before the patient was admitted at the hospital, he complained of fever, nausea and vomiting, and vague abdominal pain. The doctor examined the patient as a case of acute appendicitis and prepared for appendectomy. The nurse anticipates that this type of surgery is classified as:

Correct Answer: A

Rationale: The correct answer is A: emergency. Acute appendicitis is a condition that requires immediate surgical intervention to prevent complications like rupture. In an emergency surgery, the procedure must be done urgently to treat a life-threatening condition. In this case, the patient's symptoms indicate an urgent need for surgery to remove the inflamed appendix. Choice B: urgent, implies that surgery is needed promptly, but not immediately to prevent life-threatening complications. Choice C: elective, refers to a planned, non-urgent surgery that is scheduled in advance. Choice D: required, is a vague term and doesn't specify the urgency of the surgery, hence it is not the best classification for acute appendicitis surgery.

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