NCLEX-RN
Implementation Questions
Extract:
Question 1 of 5
A client begins to experience seizure activity while in bed. The nurse should provide which intervention to prevent aspiration?
Correct Answer: D
Rationale: Positioning the client on one side with the head flexed forward allows the tongue to fall forward and facilitates the drainage of secretions, which could help prevent aspiration. The nurse would not raise the head of the client's bed. The nurse would remove restrictive clothing and the pillow and raise the padded side rails, if present, but these actions would not decrease the risk of aspiration; rather, they are general safety measures to use during seizure activity.
Question 2 of 5
A primipara is being evaluated in the clinic during her second trimester of pregnancy. The nurse checks the fetal heart rate (FHR) and notes that it is 190 beats/min. What is the appropriate initial nursing action?
Correct Answer: C
Rationale: The FHR should be between 120 and 160 beats/min. In this situation, the FHR is elevated from the normal range, and the nurse should consult with the primary health care provider. The FHR would be documented, but option 3 is the appropriate action. The nurse would not tell the client that the FHR is fast at this point in time. Option 4 is an inappropriate action.
Question 3 of 5
Which is the most important laboratory result for the nurse to present to the primary health care provider on a client who is receiving total parenteral nutrition (TPN)?
Correct Answer: B
Rationale: Serum electrolyte levels are critical to monitor in a client receiving TPN because TPN solutions contain high concentrations of glucose and electrolytes, which can lead to imbalances such as hyperkalemia, hypokalemia, or hyponatremia. These imbalances can cause serious complications, including cardiac dysrhythmias or neurological issues. While white blood cell count, arterial blood gas levels, and hemoglobin and hematocrit levels are important, they are not as directly related to the immediate risks associated with TPN administration as electrolyte levels.
Question 4 of 5
A client with a history of hypertension has been prescribed triamterene. The nurse provides information to the client about the medication and instructs the client to avoid consuming which fruit?
Correct Answer: C
Rationale: Triamterene is a potassium-retaining diuretic, and the client should avoid foods that are high in potassium. Fruits that are naturally higher in potassium include avocados, bananas, oranges, mangoes, cantaloupe, strawberries, nectarines, papayas, and dried prunes.
Question 5 of 5
The nurse is caring for a client who is scheduled an arthrogram involving the use of a contrast medium. Which action by the nurse is the priority?
Correct Answer: A
Rationale: Because of the risk of allergy to contrast medium, the nurse places the highest priority on assessing whether the client has an allergy to iodine or shellfish. The nurse also reinforces information about the test and reminds the client about the need to remain still during the procedure. It is helpful to have the client void before the procedure for comfort.