NCLEX Trainer Test 3
Question 1 of 5.
Extract:A client is admitted with the following symptoms: dependent pitting edema, abdominal distention, and a recent 10-lb weight gain. The client has received 80 mg of furosemide (Lasix).
Which of the following nursing observations is MOST important to report to the next shift?
A. Complaints of nausea and vomiting.
B. Urine output of 200 cc in 2 hours.
C. Quiet and withdrawn behavior after lunch.
D. Blood pressure changes from 160/90 to 150/90.
Explanation: Strategy: The topic of the question is unstated. Read the answers for clues. (1) further signs and symptoms of right-sided heart failure; not a priority (2) correct-furosemide is diuretic, which warrants close observation of the client's urine output (3) further signs and symptoms of right-sided heart failure; not a priority (4) may occur as a result of volume loss, but is not a priority over answer choice #2
Question 2 of 5.
An alert adult who has terminal cancer says to the home care nurse, 'When the time comes for me to go, I don't want to be in pain and I don't want you to try to resuscitate me. Please promise me you won't.' How should the nurse respond?
A. Of course, I will do as you wish.
B. I am obligated to try and preserve life.
C. Do you have advance directives? These need to be in your record.
D. Be sure to tell each nurse your desires.
Explanation: Asking about advance directives ensures the client's wishes are documented and legally binding, facilitating appropriate end-of-life care.
Question 3 of 5.
An adult is receiving lithium carbonate 600 mg tid. Which of the following observations is of greatest concern to the nurse?
A. The serum lithium level is 1.0 mEq/L.
B. The client states that she is going to go on a low-sodium diet.
C. The client has gaining 10 lb in the last three months.
D. The client says, 'I always drink a lot of water when I take the pills.'
Explanation: A low-sodium diet increases lithium retention, risking toxicity, a serious concern requiring immediate education or intervention.
Question 4 of 5.
An adult has the following blood gasses: pH=7.52, pCO2=50, HCO3=35, and pO2=90. What is most likely to be in the client's history of presenting signs and symptoms?
A. Persistent diarrhea
B. Frequent vomiting
C. Anxiety attack
D. Emphysema
Explanation: High pH and HCO3 indicate metabolic alkalosis, commonly caused by frequent vomiting, losing gastric acid.
Question 5 of 5.
Docusate sodium (Colace) is ordered for an adult who had a myocardial infarction yesterday. The client asks the nurse why docusate sodium is prescribed. The nurse's response should include which information?
A. Colace is prescribed to make it take longer for blood to clot.
B. Colace makes it easier for the client to relax and reduce stress.
C. Colace helps lower cholesterol levels.
D. Colace reduces straining at stool.
Explanation: Docusate sodium is a stool softener, reducing straining during bowel movements, which decreases cardiac strain post-MI.
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