Free NCLEX-RN Practice Questions & Test 1

An alert client with symptomatic hypoglycemia should receive a rapidly absorbed source of glucose, such as glucose tablets or juice. The blood glucose should then be rechecked after about 15 minutes. If it remains low, treatment should be repeated.

The findings are compatible with circulatory overload. The client has received 600 mL in 45 minutes, so the first action is to slow the IV infusion. Other actions may follow rapidly, including elevating the head of the bed and notifying the PHCP. The IV catheter should not be removed because it may be needed for medication administration.

A temperature higher than 100°F (37.8°C) requires the nurse to delay hanging the blood and notify the PHCP. The PHCP may determine whether the transfusion should proceed or whether another prescribed intervention is needed.

Acute gastrointestinal bleeding can cause low fluid volume, which can decrease cardiac output and lead to hypovolemic shock. This is the priority actual problem among the choices.

Expected findings include the drainage system below the client’s chest, about 50 mL of drainage in the collection chamber, an occlusive dressing at the insertion site, and fluctuation of water in the water-seal chamber during inhalation and exhalation. Excessive water-seal bubbling may indicate an air leak, and suction-control bubbling should be gentle rather than vigorous.

Priority burn care includes assessing and maintaining airway patency, administering oxygen as prescribed, and elevating unfractured extremities to help reduce edema and support circulation. IV fluid resuscitation is also important in major burns, although it is not one of the listed choices.

When the serum glucose level falls to about 250 to 300 mg/dL during DKA treatment, dextrose is added to the IV solution while insulin therapy continues to allow correction of ketosis without causing hypoglycemia.

An increased respiratory rate is the earliest detectable sign of acute respiratory distress syndrome. Other respiratory findings such as dyspnea, accessory-muscle retractions, and crackles develop later.

Mean arterial pressure (MAP) is the most important parameter because CRRT without a hemodialysis machine requires adequate perfusion pressure, with MAP maintained above 60 mm Hg.

A rising intracranial pressure is associated with increasing temperature and blood pressure along with decreasing pulse and respirations. Respiratory irregularities may also occur.

Anaphylaxis requires immediate action. The nurse should quickly assess respiratory status, administer oxygen, and document the event, interventions, and response. The nurse should remain with the client while additional help is obtained. Normal saline, rather than D5W, is used for IV fluid support as prescribed.

Both the CVP and MAP are low, indicating inadequate circulating volume and tissue perfusion. Increasing the IV fluid rate is the priority intervention to restore fluid volume and improve perfusion.

The findings are consistent with stage 2 shock: systolic blood pressure is less than 100 mm Hg, urinary output is decreased, and confusion is present. Restlessness and agitation are also compatible with worsening cerebral perfusion.

The suspected shock is cardiogenic and occurs in the setting of heart failure exacerbation. Dopamine can support cardiac contractility and induce vasoconstriction, making restoration of cardiac function the priority.

The listed findings that fit the supplied sepsis criteria are a temperature of 102°F (38.9°C), heart rate of 96 beats/minute, and MAP of 65 mm Hg. The supplied criteria include fever above 100.9°F (38.3°C), heart rate above 90 beats/minute, and MAP below 70 mm Hg.