NCLEX-RN
Implementation Questions
Extract:
Question 1 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 2 of 5
The nurse is asked to assist another health care team member with providing care for a client. On entering the client's room, the nurse notes that the client is placed in this position (refer to figure). After maintaining the client position, what should the nurse interpret that this client is most likely being treated for?
Correct Answer: A
Rationale: A client in shock is placed in a modified Trendelenburg's position that includes elevating the legs, leaving the trunk flat, and elevating the head and shoulders slightly. This position promotes increased venous return from the lower extremities without compressing the abdominal organs against the diaphragm. The Trendelenburg position is no longer recommended for hypotensive clients because the client is predisposed to aspiration and worsens gas exchange. The remaining options identify conditions in which the head of the client's bed would be elevated.
Question 3 of 5
The nurse is caring for an infant diagnosed with laryngomalacia (congenital laryngeal stridor). In which position should the nurse place the infant to decrease the incidence of stridor?
Correct Answer: D
Rationale: The prone position with the neck hyperextended improves the child's breathing. Based on that information, none of the remaining options are appropriate positions.
Question 4 of 5
The nurse prepares to administer an enteral feeding to a client through a nasogastric tube (NGT). Which is the priority intervention for the nurse to complete before administering the feeding?
Correct Answer: A
Rationale: The nurse avoids injecting any substance into a client's NGT before verifying tube placement because NGTs can migrate out of the stomach. If the NGT is not in the correct location, subsequent injections or feedings through the tube can lead to serious complications such as aspiration. None of the remaining options are priorities before administering an enteral feeding.
Question 5 of 5
The nurse is caring for an infant after a pyloromyotomy is performed to treat hypertrophic pyloric stenosis. In which position should the nurse place the infant after surgery?
Correct Answer: C
Rationale: After pyloromyotomy, the head of the bed is elevated, and the infant is placed prone to reduce the risk of aspiration. Based on this information, the remaining options are incorrect positions after this type of surgery. The surgeon's prescriptions for positioning should always be followed.