PNLE 1 Part 3 C.

Hyperphosphatemia

51.When caring for a male client with a 3-cm stage D. Hypercalcemia

I
54.Nurse Len is administering sublingual
pressure ulcer on the coccyx, which of the nitrglycerin
following
(Nitrostat) to the newly admitted client.
actions can the nurse institute independently? Immediately

A. Massaging the area with an astringent every 2 afterward, the client may experience:
hours.
A. Throbbing headache or dizziness
B. Applying an antibiotic cream to the area three
B. Nervousness or paresthesia.
times
C. Drowsiness or blurred vision.
per day.
D. Tinnitus or diplopia.
C. Using normal saline solution to clean the ulcer
and 55.Nurse Michelle hears the alarm sound on the
telemetry
applying a protective dressing as necessary.
monitor. The nurse quickly looks at the monitor
D. Using a povidone-iodine wash on the ulceration
and notes
three
that a client is in a ventricular tachycardia. The
times per day.
nurse
52.Nurse Oliver must apply an elastic bandage to a
rushes to the client’s room. Upon reaching the
client’s
client’s
ankle and calf. He should apply the bandage
bedside, the nurse would take which action first?
beginning at
A. Prepare for cardioversion
the client’s:
B. Prepare to defibrillate the client
A. Knee
C. Call a code
B. Ankle
D. Check the client’s level of consciousness
C. Lower thigh
56.Nurse Hazel is preparing to ambulate a female
D. Foot
client.
53.A 10 year old child with type 1 diabetes
The best and the safest position for the nurse in
develops
assisting
diabetic ketoacidosis and receives a continuous
the client is to stand:
insulin
A. On the unaffected side of the client.
infusion. Which condition represents the greatest
risk to B. On the affected side of the client.
this child? C. In front of the client.
A. Hypernatremia D. Behind the client.
B. Hypokalemia
57.Nurse Janah is monitoring the ongoing care is an emergency phone call. The appropriate
given to the nursing

potential organ donor who has been diagnosed action is to:

with brain
A. Immediately walk out of the client’s room and
death. The nurse determines that the standard of
answer the phone call.
care had
B. Cover the client, place the call light within
been maintained if which of the following data is
reach, and
observed?
answer the phone call.
A. Urine output: 45 ml/hr
C. Finish the bed bath before answering the phone
B. Capillary refill: 5 seconds call.

C. Serum pH: 7.32 D. Leave the client’s door open so the client can
be
D. Blood pressure: 90/48 mmHg
monitored and the nurse can answer the phone
58. Nurse Amy has an order to obtain a urinalysis
call.
from a
60. Nurse Janah is collecting a sputum specimen
male client with an indwelling urinary catheter.
for culture
The nurse
and sensitivity testing from a client who has a
avoids which of the following, which contaminate
productive
the
cough. Nurse Janah plans to implement which
specimen?
intervention
A. Wiping the port with an alcohol swab before
to obtain the specimen?
inserting the syringe.
A. Ask the client to expectorate a small amount of
B. Aspirating a sample from the port on the
sputum into the emesis basin.
drainage
B. Ask the client to obtain the specimen after
bag.
breakfast.
C. Clamping the tubing of the drainage bag.
C. Use a sterile plastic container for obtaining the
D. Obtaining the specimen from the urinary
specimen.
drainage
D. Provide tissues for expectoration and obtaining
bag.
the
59.Nurse Meredith is in the process of giving a
specimen.
client a bed

bath. In the middle of the procedure, the unit

1. Answer: (C) Using normal saline solution to
secretary
clean the ulcer
calls the nurse on the intercom to tell the nurse
and applying a protective dressing as necessary.
that there
Washing
the area with normal saline solution and applying ventricular tachycardia, there is a significant
a decrease in

protective dressing are within the nurse’s realm of cardiac output. However, checking the
unresponsiveness
interventions and will protect the area. Using a
povidoneiodine wash and an antibiotic cream ensures whether the client is affected by the
require a physician’s decreased

order. Massaging with an astringent can further cardiac output.

damage
56. Answer: (B) On the affected side of the client.
the skin. When

52. Answer: (D) Foot. An elastic bandage should walking with clients, the nurse should stand on
be applied the affected

form the distal area to the proximal area. This side and grasp the security belt in the midspine
method area of the

promotes venous return. In this case, the nurse small of the back. The nurse should position the
should free hand

begin applying the bandage at the client’s foot. at the shoulder area so that the client can be
Beginning at pulled toward

the ankle, lower thigh, or knee does not promote the nurse in the event that there is a forward fall.
venous The client

return. is instructed to look up and outward rather than at

his or
53. Answer: (B) Hypokalemia. Insulin
administration causes her feet.

glucose and potassium to move into the cells, 57. Answer: (A) Urine output: 45 ml/hr. adequate
causing perfusion

hypokalemia. must be maintained to all vital organs in order for

the client
54. Answer: (A) Throbbing headache or dizziness.
Headache to remain visible as an organ donor. A urine
output of 45 ml
and dizziness often occur when nitroglycerin is
taken at the per hour indicates adequate renal perfusion. Low
blood
beginning of therapy. However, the client usually
develops pressure and delayed capillary refill time are
circulatory
tolerance
system indicators of inadequate perfusion. A
55. Answer: (D) Check the client’s level of
serum pH of
consciousness. Determining unresponsiveness is
7.32 is acidotic, which adversely affects all body
the first
tissues.
step assessment action to take. When a client is in
58. Answer: (D ) Obtaining the specimen from the organisms. If the procedure for obtaining the
urinary specimen is

drainage bag. A urine specimen is not taken from not sterile, then the specimen is not sterile, then
the the

urinary drainage bag. Urine undergoes chemical specimen would be contaminated and the results
changes of the test

while sitting in the bag and does not necessarily would be invalid.
reflect the

current client status. In addition, it may become

contaminated with bacteria from opening the

system.

59. Answer: (B) Cover the client, place the call

light within

reach, and answer the phone call. Because

telephone call is

an emergency, the nurse may need to answer it.

The other

appropriate action is to ask another nurse to

accept the call.

However, is not one of the options? To maintain

privacy

and safety, the nurse covers the client and places

the call

light within the client’s reach. Additionally, the

client’s door

should be closed or the room curtains pulled

around the

bathing area.

60. Answer: (C) Use a sterile plastic container for

obtaining the

specimen. Sputum specimens for culture and

sensitivity

testing need to be obtained using sterile

techniques

because the test is done to determine the

presence of