NCLEX-PN Test #1 1 — Questions and Answers
Question 1: A client with type 2 diabetes mellitus asks why blood glucose monitoring is important. Which response by the nurse is most accurate?
- It replaces the need for a hemoglobin A1C test
- It helps determine how well the treatment plan is working (Correct answer)
- It is only necessary when feeling symptomatic
- It eliminates the need for dietary modifications
Correct answer: It helps determine how well the treatment plan is working
Blood glucose monitoring helps the client and healthcare team evaluate how well the current treatment plan (diet, exercise, medications) is controlling blood sugar levels.
Self-monitoring of blood glucose (SMBG) is a cornerstone of diabetes management. It provides real-time data about how diet, physical activity, medications, stress, and illness affect blood sugar levels. This information allows the healthcare team to adjust the treatment plan as needed. SMBG does not replace A1C testing, which measures average glucose over 2-3 months. Monitoring is recommended regularly, not just when symptomatic, because hyperglycemia can be asymptomatic. It also does not eliminate the need for dietary modifications, which remain essential to diabetes care.
Question 2: A nurse is caring for a client with a nasogastric (NG) tube connected to low intermittent suction. Which electrolyte imbalance should the nurse monitor for most closely?
- Hyperkalemia
- Hypernatremia
- Hypokalemia (Correct answer)
- Hypercalcemia
Correct answer: Hypokalemia
Gastric suctioning removes potassium-rich gastric secretions, placing the client at risk for hypokalemia.
Gastric secretions contain significant amounts of potassium, hydrogen, and chloride ions. Prolonged nasogastric suctioning removes these electrolytes from the body, leading to hypokalemia (low potassium) and metabolic alkalosis (loss of hydrogen and chloride ions). Hypokalemia can cause dangerous cardiac dysrhythmias, muscle weakness, and ileus. The nurse should monitor serum potassium levels regularly, assess for signs of hypokalemia (muscle cramps, weakness, irregular pulse), and ensure adequate potassium replacement as ordered.
Question 3: A practical nurse is assisting with the admission of a client diagnosed with pulmonary tuberculosis. Which type of isolation precautions should be implemented?
- Contact precautions
- Droplet precautions
- Airborne precautions (Correct answer)
- Standard precautions only
Correct answer: Airborne precautions
Pulmonary tuberculosis is transmitted via airborne droplet nuclei, requiring airborne precautions including a negative-pressure room and N95 respirator.
Mycobacterium tuberculosis is transmitted through airborne droplet nuclei that remain suspended in the air for prolonged periods. Airborne precautions require placement in a negative-pressure airborne infection isolation room (AIIR), use of N95 or higher respirators by healthcare personnel, and keeping the door closed. Contact precautions are for organisms spread by direct or indirect contact. Droplet precautions are for organisms spread by large respiratory droplets (e.g., influenza). Standard precautions alone are insufficient because TB can remain airborne and travel long distances through air currents.
Question 4: A client is receiving heparin therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of heparin?
- Prothrombin time (PT)
- International normalized ratio (INR)
- Activated partial thromboplastin time (aPTT) (Correct answer)
- Platelet count
Correct answer: Activated partial thromboplastin time (aPTT)
The aPTT is the laboratory test used to monitor the therapeutic effectiveness of unfractionated heparin therapy.
Unfractionated heparin works by enhancing antithrombin III activity, which inhibits several clotting factors in the intrinsic pathway. The activated partial thromboplastin time (aPTT) measures the intrinsic pathway and is the standard test for monitoring heparin therapy. The therapeutic goal is typically 1.5 to 2.5 times the normal control value. PT and INR are used to monitor warfarin (Coumadin) therapy, which affects the extrinsic pathway. While platelet count should be monitored for heparin-induced thrombocytopenia (HIT), it does not measure anticoagulant effectiveness.
Question 5: When caring for a client in the immediate post-operative period, which assessment finding should the nurse report first?
- Temperature of 99.2°F (37.3°C)
- Urine output of 20 mL over the past hour (Correct answer)
- Mild incisional pain rated 3/10
- Blood pressure of 128/78 mmHg
Correct answer: Urine output of 20 mL over the past hour
A urine output of 20 mL/hour is below the minimum acceptable output of 30 mL/hour and may indicate inadequate renal perfusion or hypovolemia.
Minimum acceptable urine output for an adult is 30 mL/hour (0.5 mL/kg/hour). A urine output of 20 mL/hour falls below this threshold and may indicate decreased renal perfusion due to hypovolemia, hypotension, or other complications. This requires immediate reporting and intervention. A temperature of 99.2°F is a low-grade fever common in the first 24-48 hours post-operatively due to the inflammatory response. Mild pain rated 3/10 is expected and manageable. A blood pressure of 128/78 is within normal limits.
Question 6: A nurse is reinforcing discharge teaching for a client prescribed warfarin (Coumadin). Which dietary instruction is most important?
- Increase intake of iron-rich foods
- Avoid all green vegetables entirely
- Maintain a consistent intake of vitamin K-containing foods (Correct answer)
- Drink at least 3 liters of fluid daily
Correct answer: Maintain a consistent intake of vitamin K-containing foods
Clients on warfarin should maintain consistent vitamin K intake because vitamin K counteracts warfarin's anticoagulant effect.
Warfarin works by inhibiting vitamin K-dependent clotting factors (II, VII, IX, X). Vitamin K is the antidote for warfarin because it promotes the synthesis of these clotting factors. Clients should not avoid vitamin K foods entirely but rather maintain a consistent daily intake. Sudden increases in vitamin K intake can decrease warfarin's effectiveness, while sudden decreases can increase bleeding risk. Dark green leafy vegetables (spinach, kale, broccoli) are high in vitamin K. The goal is consistency, not elimination. Iron-rich foods and fluid intake are not directly related to warfarin therapy management.
NCLEX-PN Test #1 1
A client with type 2 diabetes mellitus asks why blood glucose monitoring is important.
Which response by the nurse is most accurate?