NCLEX-RN
Evaluation Questions
Extract:
Question 1 of 5
The nurse is reviewing the results of a client's phenytoin level that was drawn that morning. The nurse is preparing to discharge once the level is therapeutic. Which result indicates that this goal has been met?
Correct Answer: C
Rationale: The therapeutic range for serum phenytoin levels is 10 to 20 mcg/mL (39.68 to 79.36 mcmol/L) in clients with normal serum albumin levels and renal function. A level below this range indicates that the client is not receiving sufficient medication and is at risk for seizure activity. In this case, the medication dose should be adjusted upward. A level above the therapeutic range indicates that the client is entering the toxic range and is at risk for toxic side effects of the medication.
Question 2 of 5
The nurse is caring for a client who has returned from the postanesthesia care unit after prostatectomy. The client has a three-way Foley catheter with an infusion of continuous bladder irrigation (CBI). Which color description of the urinary drainage should lead the nurse to determine that the flow rate is adequate?
Correct Answer: C
Rationale: The infusion of bladder irrigant is not at a preset rate; rather, it is increased or decreased to maintain urine that is a clear, pale yellow color or has just a slight pink tinge. The infusion rate should be increased if the drainage is cherry colored or if clots are seen. Alternatively, the rate can be slowed down slightly if the returns are as clear as water.
Question 3 of 5
The nurse is assigned to care for a client diagnosed with acquired immunodeficiency syndrome (AIDS) who is receiving amphotericin B for a fungal respiratory infection. Which would indicate an adverse effect of the medication?
Correct Answer: A
Rationale: Clients receiving amphotericin B may develop hypokalemia, which can be severe and lead to extreme muscle weakness and electrocardiogram changes. Distal renal tubular acidosis commonly occurs, and this contributes to the development of hypokalemia. High potassium levels do not occur. The medication does not cause sodium, chloride, or calcium levels to fluctuate.
Question 4 of 5
A client who had a laryngectomy for laryngeal cancer has started oral intake. The nurse determines that the first stage of dietary advancement has been tolerated when the client ingests which type of diet without aspirating or choking?
Correct Answer: D
Rationale: Oral intake after laryngectomy is started with semisolid foods. When the client can manage this type of food, liquids may be introduced. A bland diet is not appropriate. The client may not be able to tolerate the texture of some of the solid foods that would be included in a bland diet. Thin liquids are not given until the risk of aspiration is negligible.
Question 5 of 5
The nurse is monitoring the nutritional status of a client who is receiving enteral nutrition. Which should the nurse monitor as the best clinical indicator of the client's nutritional status?
Correct Answer: D
Rationale: A serum prealbumin level is the most important parameter for determining the effectiveness of a client's nutritional management and nutritional status. Because prealbumin is a major plasma protein with a short half-life, it is sensitive to changes in protein synthesis and catabolism, and it is thus the best clinical indicator of nutritional status. It is a better nutritional index than a daily weight because body weight can be skewed quickly by changes in total body fluid. It is also a better index than anthropomorphic measurements because nutritional status is not necessarily related to skinfold thickness. The calorie count reports the total calories provided to the client without data regarding the client's use of the calories and nutrients.