on morning rounds the nurse finds a somnolent client with a blood glucose of 89 mgdl a sulfonurea and a proton pump inhibitor are scheduled to be admi
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Nursing Elites

NCLEX-PN

Kaplan NCLEX Question of The Day

1. On morning rounds, the nurse finds a somnolent client with a Blood glucose of 89 mg/dL. A sulfonurea and a proton pump inhibitor are scheduled to be administered. What is the nurse's best action?

Correct answer: A

Rationale: The correct action is to give the proton pump inhibitor and hold the sulfonurea until the client eats. Sulfonureas should be held for blood glucose levels below 100 mg/dL until the client has food to prevent hypoglycemia. Giving the proton pump inhibitor is appropriate and does not need to be delayed. Option B is incorrect because holding both medications without taking appropriate action may lead to further complications. Option C is not the best choice as it does not address the need to hold the sulfonurea until the client eats. Option D is incorrect because administering the medications without ensuring the client eats may lead to hypoglycemia.

2. The client is cared for by a nurse and calls for the nurse to come to the room, expressing feeling unwell. The client's vital signs are BP: 130/88, HR: 102, RR: 28. What should the nurse do next?

Correct answer: A

Rationale: Correct! The client's vital signs indicate tachycardia and tachypnea, which could be indicative of hypoxia. Administering a PRN anxiolytic would not address the underlying issue and could mask deterioration. Reassuring the client without further assessment or intervention could lead to a delay in appropriate care if there is a serious underlying cause for the symptoms. Determining the Glasgow Coma Scale is not relevant to the client's presenting symptoms of feeling unwell and suspecting something is wrong, coupled with abnormal vital signs.

3. A client goes to the Emergency Department with acute respiratory distress and the following arterial blood gases (ABGs): pH 7.35, PCO2 40 mmHg, PO2 63mmHg, HCO3 23, and oxygenation saturation (SAO2) 93%. Which of the following represents the best analysis of the etiology of these ABGs?

Correct answer: D

Rationale: A combined low PO2 and low SAO2 indicates hypoxia. The pH, PCO2, and HCO3 are normal. ABGs are not necessarily altered in TB or pleural effusion. In pneumonia, the PO2 and PCO2 might be low because hypoxia stimulates hyperventilation, but the best analysis in this case is hypoxia due to the combination of low PO2 and low SAO2.

4. The client is scheduled for surgical repair of a detached retina. What is the most likely preoperative nursing diagnosis for this client?

Correct answer: A

Rationale: The correct preoperative nursing diagnosis for a client scheduled for surgical repair of a detached retina is 'Anxiety related to loss of vision and potential failure to regain vision.' A client facing the threat of permanent blindness due to a detached retina is likely to experience anxiety. Addressing this anxiety is crucial before providing education, as severe anxiety can hinder the client's ability to absorb new information. The nurse should offer emotional support, encourage the client to express concerns, and clarify any misconceptions. Acute pain is not a typical symptom of a detached retina, and the risk of infection preoperatively is minimal, making choices C and D less relevant in this scenario.

5. Which client is at risk for hypomagnesemia?

Correct answer: D

Rationale: The correct answer is the client admitted with alcohol abuse. Alcoholics tend to have poor nutrition due to decreased food intake, which is a common source of magnesium. Additionally, alcohol suppresses the release of ADH, leading to diuresis and magnesium loss. Choice A is incorrect because a history of heart disease does not directly increase the risk of hypomagnesemia. Choice B is incorrect as taking magnesium-based antacids would not put the client at risk for hypomagnesemia; in fact, it would help prevent it. Choice C is also incorrect as a parathyroid disorder is not typically associated with an increased risk of hypomagnesemia.

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