NCLEX-PN Test #22 2 — Questions and Answers

Question 1: A nurse is caring for a client with cirrhosis who is experiencing ascites. Which dietary modification should the nurse anticipate?

High-protein, high-calorie diet
Sodium-restricted diet (Correct answer)
High-fat, low-carbohydrate diet
Unrestricted fluid intake

Correct answer: Sodium-restricted diet

Sodium restriction is the primary dietary modification for ascites because sodium retention contributes to fluid accumulation in the peritoneal cavity.

Ascites in cirrhosis occurs due to portal hypertension, decreased albumin production (reduced oncotic pressure), and activation of the renin-angiotensin-aldosterone system causing sodium and water retention. A sodium-restricted diet (typically 2,000 mg/day or less) is fundamental to managing ascites. Fluid restriction may also be necessary if serum sodium drops below 125 mEq/L. While adequate protein intake is important, excessive protein may worsen hepatic encephalopathy in advanced cirrhosis. Additional treatments include diuretics (spironolactone is first-line), paracentesis for tense ascites, and in refractory cases, transjugular intrahepatic portosystemic shunt (TIPS).

Question 2: A client is prescribed lithium carbonate for bipolar disorder. Which laboratory value requires the nurse to hold the medication and notify the provider?

Serum lithium level of 0.8 mEq/L
Serum sodium level of 140 mEq/L
Serum lithium level of 2.1 mEq/L (Correct answer)
Serum creatinine of 0.9 mg/dL

Correct answer: Serum lithium level of 2.1 mEq/L

A serum lithium level of 2.1 mEq/L exceeds the therapeutic range (0.6-1.2 mEq/L) and indicates lithium toxicity.

The therapeutic serum lithium level for maintenance therapy is 0.6-1.2 mEq/L. Levels above 1.5 mEq/L are considered toxic, and levels above 2.0 mEq/L can be life-threatening. Early signs of toxicity include nausea, vomiting, diarrhea, fine hand tremor, and drowsiness. Severe toxicity causes coarse tremors, confusion, seizures, cardiac dysrhythmias, and renal failure. A lithium level of 2.1 mEq/L requires immediate intervention. The medication must be held, the provider notified, and the client monitored closely. Factors that increase lithium levels include dehydration, sodium depletion, renal impairment, and certain medications (NSAIDs, ACE inhibitors, thiazide diuretics). A lithium level of 0.8, sodium of 140, and creatinine of 0.9 are all within normal limits.

Question 3: A nurse is reinforcing teaching with a client newly diagnosed with glaucoma. Which statement by the client indicates effective teaching?

I should stop taking the eye drops once my symptoms improve
I need to use my prescribed eye drops consistently to control eye pressure (Correct answer)
Glaucoma can be cured with surgery so drops are temporary
I only need to use eye drops when I experience eye pain

Correct answer: I need to use my prescribed eye drops consistently to control eye pressure

Glaucoma requires lifelong medication compliance to maintain controlled intraocular pressure and prevent optic nerve damage.

Glaucoma is a chronic condition characterized by increased intraocular pressure (IOP) that damages the optic nerve, leading to progressive, irreversible vision loss. Treatment aims to lower IOP through consistent use of prescribed medications (typically topical eye drops such as prostaglandin analogs, beta-blockers, or carbonic anhydrase inhibitors). Medications must be used as prescribed for life — they control the condition but do not cure it. Stopping medication when symptoms improve will allow IOP to rise again. Open-angle glaucoma is often painless, so waiting for pain is dangerous. While surgery (trabeculectomy, laser therapy) can help, it does not cure glaucoma and medication may still be needed post-operatively.

Question 4: A client with an indwelling urinary catheter develops a temperature of 101.8°F (38.8°C) and cloudy, foul-smelling urine. Which action should the nurse take first?

Remove the catheter immediately
Encourage increased fluid intake and notify the provider (Correct answer)
Administer acetaminophen for the fever
Apply a cool washcloth to the forehead

Correct answer: Encourage increased fluid intake and notify the provider

Cloudy, foul-smelling urine with fever suggests a catheter-associated urinary tract infection (CAUTI). The nurse should encourage fluids and notify the provider for further orders.

Catheter-associated urinary tract infection (CAUTI) is one of the most common healthcare-associated infections. Signs include fever, cloudy or foul-smelling urine, suprapubic tenderness, and changes in mental status (especially in elderly clients). The nurse should notify the provider, who may order a urine culture, antibiotics, and evaluation for catheter removal or replacement. Encouraging fluid intake helps dilute urine and flush bacteria. The nurse should not independently remove the catheter without a provider order, as there may be a medical indication for its continued use. Treating only the fever with acetaminophen or comfort measures addresses a symptom but does not address the underlying infection.

Question 5: A practical nurse is assisting with the care of a neonate born at 34 weeks gestation. Which assessment finding warrants immediate intervention?

Respiratory rate of 46 breaths per minute
Nasal flaring and grunting with respirations (Correct answer)
Axillary temperature of 97.6°F (36.4°C)
Weak but present suck reflex

Correct answer: Nasal flaring and grunting with respirations

Nasal flaring and grunting are signs of respiratory distress in a neonate and require immediate intervention to prevent deterioration.

Premature neonates are at high risk for respiratory distress syndrome (RDS) due to insufficient surfactant production. Signs of neonatal respiratory distress include nasal flaring, expiratory grunting (the neonate tries to maintain positive end-expiratory pressure), intercostal and subcostal retractions, tachypnea, and cyanosis. Grunting with nasal flaring requires immediate intervention including oxygen support, continuous positive airway pressure (CPAP), or surfactant administration. A respiratory rate of 46 is within the normal neonatal range (30-60). An axillary temperature of 97.6°F may need warming support but is not immediately life-threatening. A weak suck reflex is expected in a 34-week premature infant.

Question 6: A nurse is reinforcing teaching about osteoporosis prevention with a postmenopausal client. Which recommendation is most appropriate?

Avoid all physical activity to prevent fractures
Take calcium and vitamin D supplements as prescribed and perform weight-bearing exercises (Correct answer)
Limit dairy intake to reduce cholesterol
Begin hormone replacement therapy without provider consultation

Correct answer: Take calcium and vitamin D supplements as prescribed and perform weight-bearing exercises

Calcium, vitamin D supplementation, and weight-bearing exercise are the cornerstone recommendations for osteoporosis prevention.

Osteoporosis prevention and management requires a multi-faceted approach. The National Osteoporosis Foundation recommends calcium intake of 1,200 mg/day for women over 50 and vitamin D of 800-1,000 IU/day to support calcium absorption. Weight-bearing exercises (walking, jogging, dancing, stair climbing) and resistance training stimulate osteoblast activity and increase bone density. Avoiding physical activity actually accelerates bone loss. Dairy products are an excellent source of calcium and should not be avoided unless medically indicated. Hormone replacement therapy may be considered for some postmenopausal women but requires careful evaluation by a provider due to associated risks (blood clots, breast cancer) and should never be started without medical supervision.

NCLEX-PN Test #22 2

A nurse is caring for a client with cirrhosis who is experiencing ascites.
Which dietary modification should the nurse anticipate?