NCLEX-RN Practice Test #12 2 Flashcards

The RN is supervising a nursing team of one LPN and one nursing assistant (NA). Which task is appropriate to delegate to the LPN?

Answer: Administer a scheduled oral medication to a stable post-op client

LPN scope of practice includes administering medications (oral, IM, subcutaneous, topical — IV varies by state) to stable clients. Initial assessments, care plan development, and evaluation of client teaching are within the RN scope and cannot be delegated to an LPN. The RN retains accountability for all delegated tasks.

A client with sepsis meets SIRS criteria: HR 118, RR 26, temperature 38.8°C, WBC 14,000. The nurse is implementing the Sepsis Hour-1 Bundle. Which intervention is the priority first step?

Answer: Obtain blood cultures × 2 from two different sites before antibiotics

The Surviving Sepsis Campaign Hour-1 Bundle: (1) Measure serum lactate, (2) Obtain blood cultures × 2 before antibiotics, (3) Administer broad-spectrum antibiotics within 1 hour, (4) 30 mL/kg IV crystalloid for hypotension or lactate ≥4, (5) Vasopressors if hypotensive. Blood cultures must be drawn BEFORE antibiotics to allow identification of the causative organism.

An RN is working in the medical-surgical unit. Which client situation requires the RN to perform the assessment personally rather than accepting the LPN's report?

Answer: A client who has developed new onset confusion, declining blood pressure, and increased respiratory rate within the past hour

A client with acute clinical deterioration (new confusion, hypotension, tachypnea) requires immediate RN assessment. These findings suggest possible sepsis, neurological event, or hemodynamic instability. The RN cannot rely on secondary report when a client's condition is acutely changing — direct assessment is a non-delegatable RN responsibility.

A client with heart failure is receiving IV furosemide. Which set of assessment findings most clearly indicates a therapeutic response?

Answer: Urine output 800 mL over 4 hours, weight decreased 1.2 kg from admission, SpO₂ improved to 97%, crackles diminished

Therapeutic furosemide response in heart failure: increased urine output (diuresis), decreased body weight (fluid loss), improved SpO₂ (resolution of pulmonary edema), and reduced crackles/JVD/edema. A 1 kg weight loss approximates 1 liter of fluid removed. Hypotension indicates over-diuresis and requires dose reassessment.

The RN is caring for a client who is a DNR (Do Not Resuscitate). The client becomes unresponsive. The client's adult child arrives and demands that CPR be initiated. How should the RN respond?

Answer: Explain compassionately that the DNR represents the client's own documented wishes and reflects the highest standard of care; involve palliative care and the attending physician

A valid DNR order represents the competent client's previously documented autonomous decision and has legal standing. Family members cannot override a valid DNR. The nurse must: explain the DNR and its legal/ethical basis with compassion, contact the attending physician and palliative care, and provide supportive care (comfort measures). CPR would violate the client's expressed wishes.

A client is post-operative day 1 after a bowel resection and has a nasogastric tube to low continuous suction. The client's serum potassium is 2.8 mEq/L and sodium is 128 mEq/L. These electrolyte imbalances are most likely caused by:

Answer: Continuous NG suction removing potassium and sodium in gastric secretions, combined with restriction of oral intake

Gastric secretions contain significant amounts of sodium, potassium, hydrochloric acid, and water. Continuous NG suction depletes these electrolytes, causing hyponatremia, hypokalemia, and metabolic alkalosis. Electrolyte replacement (IV KCl for potassium, isotonic fluids for sodium) and monitoring are essential post-operatively with NG suction.