the client is receiving peritoneal dialysis if the dialysate returns cloudy the nurse should
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Nursing Elites

NCLEX-PN

Nclex Practice Questions 2024

1. If the client is receiving peritoneal dialysis and the dialysate returns cloudy, what should the nurse do?

Correct answer: B

Rationale: When the dialysate returns cloudy, it could indicate the presence of infection, and sending a specimen to the lab for evaluation is crucial to determine the cause. Documenting the finding alone, as in choice A, may not provide enough information for proper intervention. Straining the dialysate, as in choice C, is not a standard practice and may not help identify the underlying issue. Obtaining a complete blood count, as in choice D, is not directly related to addressing cloudiness in the dialysate. However, the healthcare provider might order a white blood cell count to assess for infection.

2. Which nurse should be assigned to care for the postpartal client with preeclampsia?

Correct answer: B

Rationale: The nurse with 3 years of experience in labor and delivery (answer B) should be assigned to care for the postpartal client with preeclampsia. This nurse has the most relevant experience and knowledge of possible complications associated with preeclampsia due to their background in labor and delivery. Assigning a nurse with only 2 weeks of experience on the postpartum unit (answer A) would not be suitable for handling the complexities of caring for a client with preeclampsia. Nurses with experience in surgery (answer C) or the neonatal intensive care unit (answer D) lack the specific expertise needed for managing a postpartal client with preeclampsia, making them unsuitable choices for this assignment.

3. Which information should be reported to the state Board of Nursing?

Correct answer: B

Rationale: The correct answer is 'The narcotic count has been incorrect on the unit for the past 3 days.' This information should be reported to the state Board of Nursing as it involves medication errors and potential drug diversion, which are serious issues that fall under the jurisdiction of the Board. Reporting medication discrepancies and errors in narcotic counts is crucial for patient safety and regulatory compliance. Choices A, C, and D involve different types of issues that are not within the direct purview of the Board of Nursing. Providing literature in multiple languages (Choice A), addressing billing practices (Choice C), and resolving staff performance issues (Choice D) should be handled internally or reported to the appropriate departments or authorities, such as the Joint Commission or the charge nurse.

4. A 20-year-old female has a prescription for tetracycline. While teaching the client how to take her medicine, the nurse learns that the client is also taking Ortho-Novum oral contraceptive pills. Which instructions should be included in the teaching plan?

Correct answer: D

Rationale: When antibiotics and oral contraceptives are taken together, the effectiveness of the oral contraceptives can be reduced, increasing the risk of pregnancy. Therefore, it is important to advise the client to use an alternate method of birth control to prevent unintended pregnancy. Choices A, B, and C are incorrect because there is no evidence to suggest that oral contraceptives decrease the effectiveness of tetracycline, cause nausea, or result in toxicity when taken with antibiotics.

5. The doctor orders 2% nitroglycerin ointment in a 1-inch dose every 12 hours. Proper application of nitroglycerin ointment includes:

Correct answer: A

Rationale: Proper application of nitroglycerin ointment involves rotating application sites to prevent skin irritation. It should be applied to the back and upper arms, not restricted to the chest, making option B incorrect. Rubbing it into the skin, as indicated in option C, is not recommended for nitroglycerin ointment as it can lead to faster absorption and potential side effects. The correct way is to cover it with a thin paper dressing, not gauze as mentioned in option D, to ensure proper absorption and prevent the medication from evaporating too quickly.

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