Test #23 1 Flashcards
6 cards from real NCLEX practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Test #23 1 flashcards as text
A nurse is assessing a client with chronic kidney disease. Which laboratory value would the nurse expect to be elevated?
Answer: Serum creatinine
In chronic kidney disease, the kidneys lose their ability to filter waste products, causing serum creatinine to accumulate and rise above normal levels. GFR decreases, not increases, and hemoglobin and albumin typically fall.
A nurse is caring for a postoperative client who received general anesthesia 2 hours ago. The client is drowsy but arousable. Which action should the nurse prioritize?
Answer: Monitor oxygen saturation and respiratory rate every 15 minutes
Residual anesthetic effects can depress the respiratory center, making respiratory monitoring the priority in the immediate postoperative period. Frequent assessment of O2 saturation and respiratory rate allows early detection of airway compromise.
A nurse is teaching a client with heart failure about dietary restrictions. Which statement by the client indicates a need for further teaching?
Answer: 'I can use as much salt as I like because I take a diuretic.'
Clients with heart failure must restrict sodium intake regardless of diuretic use. Diuretics help remove excess fluid but do not eliminate the need for a low-sodium diet, which prevents fluid retention.
A nurse is caring for a client receiving IV heparin therapy. Which finding requires the nurse to notify the provider immediately?
Answer: New onset of blood in the urine
Hematuria (blood in the urine) is a sign of bleeding, a serious complication of heparin therapy that requires immediate provider notification. An aPTT within therapeutic range and normal urine output are expected findings.
A nurse is assessing a newborn at 5 minutes of life and assigns an Apgar score. Which finding would contribute to a lower score?
Answer: No response to stimulation
The Apgar score evaluates heart rate, respiratory effort, muscle tone, reflex irritability, and color. No response to stimulation scores 0 for reflex irritability, which lowers the total score. Blue hands and feet (acrocyanosis) score 1, while a heart rate above 100 and vigorous cry each score 2.
A nurse is administering a blood transfusion. Fifteen minutes after starting the infusion, the client reports chills, back pain, and has a temperature of 38.9°C (102°F). What should the nurse do first?
Answer: Stop the transfusion and keep the IV line open with normal saline
These symptoms are classic signs of an acute hemolytic transfusion reaction, a life-threatening emergency. The nurse must stop the transfusion immediately and maintain IV access with normal saline to prevent hypotension and preserve kidney function while notifying the provider.