a nurse is performing a screening on a patient that has been casted recently on the left lower extremity which of the following statements should the
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Nursing Elites

NCLEX-PN

Quizlet NCLEX PN 2023

1. During a screening on a patient with a recent cast on the left lower extremity, which of the following statements should the nurse be most concerned about?

Correct answer: B

Rationale: The correct answer is B because pain in the left calf could indicate a potential neurovascular complication related to the casted extremity. It could suggest issues such as compartment syndrome or impaired circulation. Option A is not as concerning since not elevating the extremity may lead to swelling but is not an immediate concern. Option C indicates itching, which is common with casts and not as concerning as potential neurovascular issues. Option D, regarding arthritis in the wrists, is unrelated to the lower extremity issue being screened for.

2. Which of the following medications is not classified as a neuromuscular blocker?

Correct answer: C

Rationale: The correct answer is Pitressin. Pitressin is a hormone replacement medication and is not classified as a neuromuscular blocker. Choices A, B, and D (Anectine, Pavulon, Mivacron) are neuromuscular blockers used during anesthesia to induce muscle relaxation for various procedures. Anectine is also known as succinylcholine, Pavulon is rocuronium, and Mivacron is mivacurium. These medications act on the neuromuscular junction to block the transmission of nerve impulses, leading to muscle relaxation.

3. A client is admitted to telemetry with a diagnosis of diabetes at 3pm. At 10pm, the client is unresponsive. BP is 98/64, Resp 38, HR 100, T 97. The nurse notes a fruity smell on the client's breath. The nurse recognizes that the client is in which acid-base imbalance?

Correct answer: C

Rationale: Based on the client's unresponsiveness, fruity breath smell, and the presence of diabetes, the nurse can infer that the client is experiencing diabetic ketoacidosis (DKA). DKA is a complication of diabetes characterized by the accumulation of ketones in the body, leading to metabolic acidosis. The fruity breath smell is due to the presence of ketones. Therefore, the correct acid-base imbalance in this scenario is metabolic acidosis. Choice A, respiratory acidosis, is incorrect because the scenario does not provide evidence of primary respiratory dysfunction. Choice B, respiratory alkalosis, is incorrect as the client's condition does not align with the typical causes and symptoms of respiratory alkalosis. Choice D, metabolic alkalosis, is incorrect as the symptoms and history provided do not suggest a state of metabolic alkalosis.

4. Which of the following symptoms is most characteristic of a client with lung cancer?

Correct answer: B

Rationale: The most characteristic symptom of lung cancer is a persistent changing cough. This cough may worsen over time and may produce blood-tinged sputum. Exertional dyspnea (Choice A) is more common in chronic obstructive pulmonary disease (COPD) due to airway obstruction. Air hunger and dyspnea (Choice C) are more typical of conditions like asthma. Cough with night sweats (Choice D) is commonly associated with tuberculosis rather than lung cancer.

5. A nurse is caring for a client with an elevated urine osmolarity. The nurse should assess the client for:

Correct answer: D

Rationale: Elevated urine osmolarity indicates that the urine is concentrated, suggesting the body is trying to conserve water. This commonly occurs in conditions like dehydration or fluid volume deficit. Assessing the client for fluid volume excess, hyperkalemia, or hypercalcemia would not be the priority in this situation. Therefore, the correct answer is to assess the client for fluid volume deficit. Fluid volume excess is characterized by decreased urine osmolarity, while hyperkalemia and hypercalcemia are related to electrolyte imbalances and would not directly cause elevated urine osmolarity.

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