a nurse is calculating a clients intake and output during the last shift the client has had cup of gelatin a skinless chicken breast 1 cup of green b

NCLEX-RN

NCLEX RN Exam Prep

1. A client's intake and output are being calculated by a nurse. During the last shift, the client consumed � cup of gelatin, a skinless chicken breast, 1 cup of green beans, and 300 cc of water. The client also urinated 250 cc and had 2 bowel movements. What is this client's intake and output for this shift?

A. 420 cc intake, 250 cc output
B. 300 cc intake, 250 cc output
C. 550 cc intake, 550 cc output
D. 300 cc intake, 550 cc output

Correct answer: A

Rationale: The correct answer is 420 cc intake and 250 cc output for this shift. To calculate the intake, � cup of gelatin (approximately 120 cc) and 300 cc of water should be added together, resulting in 420 cc. Food intake like the chicken breast and green beans is not converted to cc's but may be documented for hospital protocol. Output includes urine (250 cc in this case) and other forms like vomit, diarrhea, or gastric suction. Bowel movements are not converted to cc's, but the nurse may need to document the number of stools passed. Choices B, C, and D are incorrect because they do not accurately reflect the intake and output calculations based on the information provided.

2. Which of the following lists the recommended sequence for removing soiled personal protective equipment when preparing to leave a patient's room?

A. Gown, goggles, mask, gloves, and exit the room.
B. Gloves, wash hands, remove gown, mask, and goggles.
C. Gloves, goggles, gown, mask, and wash hands.
D. Gloves, goggles, gown, mask, and wash hands.

Correct answer: D

Rationale: The correct sequence for removing soiled personal protective equipment is crucial to prevent contamination. Gloves should always be removed first as they are most likely to be contaminated. Following the removal of gloves, goggles, gown, mask, and finally washing hands is recommended. Choice A is incorrect as gloves should be removed first. Choice B is incorrect as the sequence is not in the recommended order. Choice D is incorrect as gloves should be removed before goggles.

3. What should the nurse anticipate or expect of an American Indian woman seeking help to regulate her diabetes?

A. Will comply with the treatment prescribed.
B. Has given up her belief in naturalistic causes of disease.
C. May also be seeking the assistance of a shaman or medicine man.
D. Will need extra help in dealing with her illness and may be experiencing a crisis of faith.

Correct answer: C

Rationale: When caring for an American Indian patient seeking help for diabetes, the nurse should anticipate that the patient may also seek the assistance of a shaman or medicine man in addition to biomedical treatment. This cultural practice is common among American Indians who believe in holistic healing involving body, mind, and spirit. It is important for the nurse to acknowledge and respect these cultural beliefs and practices. Choice A is incorrect because patients from different cultures may not always comply with prescribed treatments due to various factors, including cultural beliefs. Choice B is incorrect as patients seeking traditional healing methods do not necessarily give up their beliefs in naturalistic causes of disease; instead, they often complement biomedical care. Choice D is incorrect as assuming the patient is experiencing a crisis of faith is not appropriate; it is more about respecting and understanding the patient's cultural background and beliefs.

4. The categories such as ethnicity, gender, and religion illustrate which concept?

A. Family
B. Cultures
C. Spirituality
D. Subcultures

Correct answer: D

Rationale: Within cultures, various groups of people share different beliefs, values, and attitudes due to factors such as ethnicity, religion, education, occupation, age, and gender. When these distinct groups coexist within a broader culture, they are referred to as subcultures. While ethnicity, gender, and religion are important components of individuals' identities, they do not represent the concepts of family, cultures, or spirituality. The correct answer is 'Subcultures' as these categories reflect differences within a larger cultural context, emphasizing the unique characteristics shared by members of subcultural groups.

5. A child is admitted to the hospital several days after stepping on a sharp object that punctured her athletic shoe and entered the flesh of her foot. The physician is concerned about osteomyelitis and has ordered parenteral antibiotics. Which of the following actions is done immediately before the antibiotic is started?

A. The admission orders are written.
B. A blood culture is drawn.
C. A complete blood count with differential is drawn.
D. The parents arrive.

Correct answer: B

Rationale: Before starting antibiotics, a blood culture should be drawn to identify the causative organism. This step is crucial as antibiotics may interfere with the identification process. Drawing a complete blood count with differential or writing admission orders are important steps in patient care but are not as critical as obtaining a blood culture to guide appropriate antibiotic therapy. The arrival of the parents is not directly related to the immediate action required before starting antibiotics in this scenario.