a patient suffering from hyperglycemia would be experiencing

NCLEX-RN

NCLEX RN Actual Exam Test Bank

1. A patient suffering from hyperglycemia would be experiencing:

A. Low blood sugar
B. High blood sugar
C. Normal blood sugar
D. None of the above

Correct answer: B

Rationale: Hyperglycemia is a condition characterized by high blood sugar levels. In this state, there is an excess of glucose in the bloodstream. Patients with hyperglycemia are often diagnosed with diabetes. The term 'hyperglycemia' specifically refers to elevated blood sugar levels. Therefore, the correct answer is 'High blood sugar.' Choices A, C, and D are incorrect because hyperglycemia indicates elevated blood sugar levels and not low or normal levels.

2. The nurse supervises unlicensed assistive personnel (UAP) who are providing care for a patient with right lower lobe pneumonia. The nurse should intervene if which action by UAP is observed?

A. UAP splint the patient's chest during coughing.
B. UAP assist the patient to ambulate to the bathroom.
C. UAP help the patient to a bedside chair for meals.
D. UAP lower the head of the patient's bed to 15 degrees.

Correct answer: D

Rationale: The correct action for the nurse to intervene in is when the UAP lowers the head of the patient's bed to 15 degrees. This position can decrease ventilation in a patient with pneumonia, potentially worsening their condition. Choices B and C involve assisting the patient with activities of daily living and promoting mobility, which are appropriate for the patient's care. Choice A, splinting the patient's chest during coughing, can help the patient manage coughing effectively, which is also appropriate for a patient with pneumonia.

3. When placing a patient in the AP position for an X-ray, what position would the patient be in?

A. Facing the X-ray film.
B. Right side against the X-ray film.
C. Left side against the X-ray film.
D. Facing away from the X-ray film

Correct answer: D

Rationale: The AP position stands for Anteroposterior Projection. When a patient is in the AP position for an X-ray, they are facing away from the X-ray film. This positioning allows for a clear view of the structures being imaged from front to back. Choices A, B, and C are incorrect because the patient is not facing or positioned against the X-ray film in the AP position, but rather facing away from it to capture the necessary diagnostic information.

4. Which of these is a correctly stated outcome goal written by the nurse?

A. The client will walk 2 miles daily by March 19
B. The client will understand how to give insulin by discharge
C. The client will regain their former state of health by April 1
D. The client achieve desired mobility by May 7

Correct answer: A

Rationale: Outcome goals should be SMART, i.e., Specific, Measurable, Appropriate, Realistic, and Timely. Option A is the only outcome that has a specific behavior (walks daily), with measurable performance criteria (2 miles), and a time estimate for goal attainment (by March 19). Option B lacks specificity in terms of what 'understand how to give insulin' entails, and the timeline is vague ('by discharge'). Option C is not measurable or specific about what 'regain their former state of health' means. Option D does not provide a specific behavior or measurable criteria for 'desired mobility,' and the timeline is the only element that is time-bound.

5. When preparing a patient on complete bed rest to eat, at what degree angle or more should you put the head of the bed up?

A. 10
B. 15
C. 20
D. 30

Correct answer: D

Rationale: The correct answer is D: 30. When a patient is on complete bed rest, it is essential to elevate the head of the bed at a 30-degree angle or more before meals. This position helps prevent choking and aspiration of food during eating by promoting proper swallowing and digestion. Choices A, B, and C are incorrect because they do not provide the optimal elevation needed to support safe and effective feeding for a patient on complete bed rest.