ATI RN
NCLEX RN Pediatric Questions Questions
Question 1 of 5
A patient is admitted with symptoms of a recent weight gain, 3+ pitting edema of his feet, distended neck veins, and crackles in his lungs. Which of the following nursing diagnoses is most appropriate for this patient's plan of care?
Correct Answer: C
Rationale: The patient's symptoms of recent weight gain, 3+ pitting edema of his feet, distended neck veins, and crackles in his lungs are indicative of fluid volume excess. These signs and symptoms suggest that the patient is retaining too much fluid, leading to the edema and congestion in the lungs. The nursing diagnosis of Excess Fluid Volume is appropriate for this patient as it reflects the patient's current physiological state and guides the plan of care to address excess fluid accumulation through interventions such as diuretic therapy, fluid restriction, and monitoring of intake and output. Deficient fluid volume, Imbalanced nutrition more than body requirements, and Noncompliance are not appropriate nursing diagnoses given the patient's presentation of fluid overload.
Question 2 of 5
A patient is admitted who has had severe vomiting for 24 hours. She states that she is exhausted and weak. The results of an admitting ECG show flat T waves and ST segment depression. Choose the most likely potassium (K ) value for this patient.
Correct Answer: B
Rationale: The patient is displaying signs of hypokalemia (low potassium levels) due to severe vomiting. Symptoms of hypokalemia can include weakness, fatigue, and ECG changes such as flat T waves and ST segment depression. The potassium level that is most likely associated with these symptoms is 2.0mEq/L. Severe vomiting can lead to significant loss of potassium from the body, causing these abnormalities. It is important to address and correct the potassium imbalance to prevent further complications.
Question 3 of 5
After a Whippie procedure for cancer of the pancreas, a client is to receive the following intravenous (IV) fluids over 24 hours; 1000 ml D5W; 0.5 liter normal saline; 1500 ml D5NS. In addition, an antibiotic piggyback in 50 ml D5W is ordered every 8 hours. The nurse calculates that the clients IV fluid intake Tor 24 hours will be:
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 4 of 5
Approximately how much fluid is lost in acute weight loss of .5kg?
Correct Answer: C
Rationale: When a person loses 0.5 kg of weight, it is commonly assumed that most of the weight loss is due to fluid loss. The approximate fluid loss for every 0.5 kg of weight loss is around 500 ml. This estimation is based on the fact that 1 kg of body weight is approximately equivalent to 1 liter of fluid. Therefore, for a 0.5 kg weight loss, the fluid loss would be approximately 500 ml (0.5 liters).
Question 5 of 5
A patient has chronic respiratory acidosis related to long-standing lung disease. Which of the following problems is the cause?
Correct Answer: C
Rationale: Chronic respiratory acidosis is a condition where there is an excess of carbon dioxide (CO2) in the blood due to inadequate exhalation of CO2. This typically occurs as a result of hypoventilation, which is characterized by breathing at an abnormally slow rate or shallow depth. In patients with long-standing lung disease, the ability to effectively exchange gases in the lungs is compromised, leading to a buildup of CO2 in the bloodstream and subsequent respiratory acidosis. Hyperventilation, on the other hand, would result in a decrease in CO2 levels in the blood, while the loss of acid or base by the kidneys is related to metabolic acidosis or alkalosis, not respiratory acidosis. Therefore, in this case, the primary problem causing chronic respiratory acidosis is hypoventilation.