Lab Value Legends
A nurse reviews the laboratory results of a client receiving furosemide. Which finding requires the most immediate intervention?
A. Sodium 136 mEq/L
B. Potassium 2.8 mEq/L
C. Calcium 9.1 mg/dL
D. Magnesium 2.0 mg/dL
What is Answer: B — Potassium 2.8 mEq/L .
Rationale: Significant hypokalemia increases the risk for life-threatening dysrhythmias, particularly in a client receiving a loop diuretic.
Which client should the nurse assess first?
A. Client requesting pain medication for chronic back pain
B. Client with a temperature of 100.4°F (38°C)
C. Client with new-onset shortness of breath
D. Client requesting assistance with bathing
What is Answer: C
Rationale: New-onset respiratory difficulty takes priority because of the ABCs—airway and breathing.
Which finding in a 6-month-old infant requires further evaluation?
A. Rolls from abdomen to back
B. Sits with support
C. Transfers objects from one hand to the other
D. Uses a mature pincer grasp
What is Answer: D
Rationale: A mature pincer grasp generally develops around 9–12 months.
Which finding is most concerning in a client who sustained a head injury?
A. Headache rated 3/10
B. Bruising around the eye
C. Increasing level of confusion
D. Mild nausea
What is Answer: C
Which finding is most consistent with a Stage 2 pressure injury?
A. Intact skin with nonblanchable erythema
B. Partial-thickness skin loss with exposed dermis
C. Full-thickness tissue loss with exposed muscle
D. Full-thickness tissue loss with exposed bone
What is Answer: B
A client has a serum potassium level of 6.4 mEq/L. Which findings should the nurse anticipate? Select all that apply.
A. Muscle weakness
B. Peaked T waves
C. Cardiac dysrhythmias
D. Hyperactive bowel sounds
E. Flattened T waves
F. Increased deep tendon reflexes
What is Answers: A, B, C, D
Rationale: Hyperkalemia can cause muscle weakness, GI hyperactivity, and potentially fatal cardiac dysrhythmias. Peaked T waves are a classic ECG finding.
Which interventions help prevent falls in hospitalized clients? Select all that apply.
A. Keep the bed in the lowest position.
B. Keep frequently used items within reach.
C. Keep the room free of clutter.
D. Encourage clients to walk independently to maintain strength.
E. Ensure adequate lighting.
F. Place all four side rails up for every high-risk client.
What is Answers: A, B, C, E
The nurse is teaching parents about preventing injury in an infant. Which instructions are appropriate? Select all that apply.
A. Place the infant on the back for sleep.
B. Keep small objects out of reach.
C. Use pillows to position the infant during sleep.
D. Secure the infant in an appropriate car seat.
E. Keep medications locked away.
F. Place the infant to sleep on the stomach to prevent aspiration.
What is Answers: A, B, D, E
Which findings may indicate increased intracranial pressure? Select all that apply.
A. Decreasing level of consciousness
B. Projectile vomiting
C. Unequal pupils
D. Bradycardia with hypertension
E. Increased appetite
F. Widened pulse pressure
What is Answers: A, B, C, D, F
Which interventions help prevent pressure injuries? Select all that apply.
A. Reposition the client according to the individualized plan.
B. Keep skin clean and dry.
C. Assess nutritional status.
D. Massage reddened bony prominences.
E. Use pressure-redistributing surfaces when indicated.
F. Minimize moisture exposure.
What is Answers: A, B, C, E, F
NCLEX Note: Do not massage reddened bony prominences, as this can damage already compromised tissue.
A client with diabetic ketoacidosis has the following ABG results:
How should the nurse interpret these findings?
A. Respiratory acidosis with compensation
B. Respiratory alkalosis with compensation
C. Metabolic acidosis with respiratory compensation
D. Metabolic alkalosis with respiratory compensation
What is Answer: C
Rationale: The low pH and low bicarbonate indicate metabolic acidosis. The low PaCO₂ indicates respiratory compensation.
The nurse receives these four assignments. Which task is appropriate to delegate to an experienced UAP?
A. Assess a client with new confusion.
B. Teach a client how to use an incentive spirometer.
C. Obtain vital signs on a stable postoperative client.
D. Evaluate a client's response to pain medication.
What is Answer: C
Rationale: UAPs may perform routine, predictable tasks such as obtaining vital signs on stable clients. Assessment, teaching, and evaluation remain nursing responsibilities.
A toddler with gastroenteritis has had repeated vomiting and diarrhea. Which assessment finding is most concerning?
A. Heart rate of 118/min
B. Capillary refill of 4 seconds
C. Slightly decreased appetite
D. Two loose stools during the shift
What is Answer: B
Rationale: Delayed capillary refill indicates poor peripheral perfusion and possible significant dehydration.
A client suddenly develops facial drooping, right-sided weakness, and difficulty speaking. What is the nurse's priority action?
A. Give aspirin immediately.
B. Determine the time symptoms began.
C. Place the client in Trendelenburg position.
D. Encourage oral fluids.
What is Answer: B
Rationale: Determining the last-known-well/symptom onset time is critical when evaluating a client for acute ischemic stroke treatment.
A wound has thick yellow drainage, increasing pain, warmth, and surrounding erythema. Which finding should the nurse recognize as most concerning?
A. Granulation tissue
B. Wound infection
C. Normal inflammatory response
D. Epithelialization
What is Answer: B
A client receiving heparin has a platelet count that decreased from 220,000/mm³ to 92,000/mm³. Which actions should the nurse anticipate? Select all that apply.
A. Hold the heparin infusion.
B. Notify the provider.
C. Assess for bleeding.
D. Administer vitamin K.
E. Anticipate an alternative anticoagulant.
F. Continue the infusion because the platelet count remains above 50,000/mm³.
What is Answers: A, B, C, E
Rationale: The significant platelet drop raises concern for heparin-induced thrombocytopenia (HIT). Heparin should be discontinued and an alternative anticoagulant may be prescribed.
The nurse is preparing to administer medications. Which actions promote medication safety? Select all that apply.
A. Compare the medication with the MAR.
B. Verify the client's identity using two identifiers.
C. Document administration before giving the medication.
D. Assess allergies before administration.
E. Clarify an incomplete or unclear prescription.
F. Leave an unidentified medication at the bedside.
What is Answers: A, B, D, E
A child is admitted with suspected bacterial meningitis. Which nursing actions are appropriate? Select all that apply.
A. Initiate appropriate isolation precautions.
B. Monitor neurological status frequently.
C. Minimize environmental stimulation.
D. Encourage frequent ambulation.
E. Monitor for seizures.
F. Place the child in Trendelenburg position.
What is Answers: A, B, C, E
A client is experiencing a generalized tonic-clonic seizure. Which nursing actions are appropriate? Select all that apply.
A. Protect the client's head.
B. Turn the client to the side when possible.
C. Restrain the client's extremities.
D. Remove nearby objects that could cause injury.
E. Place a tongue blade in the mouth.
F. Observe and document seizure duration.
What is Answers: A, B, D, F
The nurse is assessing a chronic wound. Which findings should be documented? Select all that apply.
A. Length, width, and depth
B. Wound bed appearance
C. Type and amount of drainage
D. Odor
E. Condition of surrounding skin
F. "Looks bad"
What is Answers: A, B, C, D, E
A client with chronic kidney disease has a potassium level of 7.0 mEq/L and reports muscle weakness. The ECG shows tall, peaked T waves.
Choose TWO actions:
A. Place the client on continuous cardiac monitoring.
B. Encourage foods high in potassium.
C. Prepare to administer IV calcium as prescribed.
D. Administer potassium supplementation.
E. Restrict sodium only.
Choose TWO parameters to monitor:
F. Cardiac rhythm
G. Serum potassium
H. Visual acuity
I. Bowel sounds only
J. Hemoglobin A1C
What is Answers:
Actions: A, C
Monitor: F, G
A postoperative client suddenly becomes restless and confused. The respiratory rate is 30/min, oxygen saturation is 86%, and the client is using accessory muscles.
Choose TWO actions:
A. Apply oxygen as indicated.
B. Reassess in 30 minutes.
C. Raise the head of the bed.
D. Give the prescribed oral analgesic first.
E. Encourage the client to ambulate.
Choose TWO parameters to monitor:
F. Oxygen saturation
G. Respiratory effort
H. Bowel sounds
I. Urine color
J. Appetite
What is Answers:
Actions: A, C
Monitor: F, G
A 4-year-old develops drooling, difficulty swallowing, muffled speech, and sits leaning forward. The child appears anxious and has increasing respiratory distress.
Choose TWO actions:
A. Keep the child calm.
B. Inspect the throat with a tongue blade.
C. Prepare for emergency airway management.
D. Force the child to lie flat.
E. Obtain a throat culture immediately.
Choose TWO parameters to monitor:
F. Respiratory effort
G. Oxygen saturation
H. Bowel sounds
I. Urine specific gravity
J. Peripheral edema
What is
Answers:
Actions: A, C
Monitor: F, G
NCLEX Safety Point: Never attempt to visualize the throat with a tongue blade in a child with suspected epiglottitis because this can precipitate complete airway obstruction.
A client suddenly develops aphasia and right-sided weakness. The last known well time was 45 minutes ago.
Choose TWO actions:
A. Activate the stroke response/protocol.
B. Determine blood glucose.
C. Give food and fluids orally.
D. Delay evaluation until symptoms persist for 24 hours.
E. Administer anticoagulants independently.
Choose TWO parameters to monitor:
F. Neurological status
G. Blood glucose
H. Bowel sounds
I. Pedal pulses only
J. Urine color
What is Answers:
Actions: A, B
Monitor: F, G
An immobile client has a wound over the sacrum. The wound contains adipose tissue, but there is no exposed muscle, tendon, cartilage, or bone.
Choose TWO actions:
A. Implement pressure redistribution and repositioning.
B. Perform wound care according to the prescribed treatment plan.
C. Massage the wound bed.
D. Apply an unprescribed topical medication.
E. Keep the client in the same position to avoid disturbing the wound.
Choose TWO parameters to monitor:
F. Wound size and depth
G. Drainage and signs of infection
H. Pupil response
I. Bowel sounds
J. Visual acuity
What is Answers:
Actions: A, B
Monitor: F, G