NCLEX-PN Test #12 1 Flashcards

A client with chronic kidney disease has a serum potassium level of 6.2 mEq/L. Which food should the nurse instruct the client to avoid?

Answer: Baked potato with skin

Baked potatoes — especially with the skin — are high in potassium and should be avoided by clients with hyperkalemia or chronic kidney disease. White rice, plain pasta, and eggs are lower-potassium options generally acceptable on a renal diet. Clients with CKD must limit high-potassium foods to prevent cardiac complications.

A nurse is reviewing a client's medication list and notes the client takes warfarin. The client asks if they can take ibuprofen for a headache. What is the most appropriate response?

Answer: 'You should avoid ibuprofen because it can increase your risk of bleeding when taken with warfarin.'

NSAIDs like ibuprofen inhibit platelet aggregation and can displace warfarin from protein-binding sites, significantly increasing bleeding risk. Clients on warfarin should use acetaminophen for pain relief instead. There is no safe time of day to take ibuprofen to avoid the interaction.

A nurse is performing a focused assessment on a client who reports difficulty breathing. In which order should the nurse complete the assessment? (Place in priority order: 1=first)

Answer: Measure oxygen saturation

Oxygen saturation via pulse oximetry provides rapid, objective data about oxygenation status and should be obtained as an immediate priority in any client with respiratory distress. Visual inspection and auscultation follow. The systematic priority is: quick SpO2 check first, then inspection, then auscultation.

The nurse is teaching a client how to use a metered-dose inhaler (MDI) without a spacer. Which instruction is correct?

Answer: Hold the inhaler 1–2 inches from the open mouth, activate, and inhale slowly and deeply

Correct MDI technique without a spacer includes holding the inhaler 1–2 inches in front of an open mouth (or lips sealed around it), activating once, and inhaling slowly and deeply over 3–5 seconds, then holding the breath for 10 seconds. Rapid inhalation causes the medication to deposit in the mouth rather than reach the airways.

A nurse is caring for a client who had a thyroidectomy 12 hours ago. The client reports tingling around the mouth and in the fingertips. Which complication should the nurse suspect?

Answer: Hypocalcemia from accidental parathyroid removal

Tingling around the mouth and in the extremities (perioral and peripheral paresthesias) are classic early signs of hypocalcemia, which can occur after thyroidectomy if the parathyroid glands are inadvertently removed or damaged. This is a priority assessment finding that requires immediate provider notification and calcium monitoring.

A nurse is delegating tasks to an unlicensed assistive personnel (UAP). Which task is appropriate to delegate?

Answer: Measuring and recording urinary output for a stable postoperative client

Measuring and recording urinary output on a stable postoperative client is a routine, non-complex task within the scope of a UAP. Assessment, client education, and evaluation of medication effectiveness require clinical judgment and are within the scope of licensed nursing practice only.