the nurse is obtaining a history of an 80 year old client which statement made by the client might indicate a possible fluid and electrolyte imbalance

NCLEX-PN

Nclex 2024 Questions

1. During the history assessment of an 80-year-old client, which statement made by the client might indicate a possible fluid and electrolyte imbalance?

A. "My skin is always so dry."?
B. "I often use a laxative for constipation."?
C. "I have always liked to drink a lot of iced tea."?
D. "I sometimes have a problem with dribbling urine."?

Correct answer: B

Rationale: The correct answer is "I often use a laxative for constipation." Frequent use of laxatives can lead to diarrhea and electrolyte loss, indicating a possible fluid and electrolyte imbalance. Statements A, C, and D are not directly related to fluid and electrolyte imbalance. Statement A about dry skin may suggest dehydration, but it is less specific to electrolyte imbalance than the frequent use of laxatives. Statement C about drinking a lot of iced tea could potentially relate to fluid intake, but it doesn't directly indicate an imbalance. Statement D about dribbling urine is more indicative of a potential urinary issue rather than a fluid and electrolyte imbalance.

2. Which of the following attitudes is essential in a nurse who assists clients during crises?

A. viewing crisis intervention as the first step in solving bigger problems
B. wanting to help clients solve all problems identified
C. taking an active role in guiding the process
D. feeling that work requires identification with all of a client's problems

Correct answer: A

Rationale: Viewing crisis intervention as the first step in solving bigger problems is essential in a nurse who assists clients during crises. This approach focuses on addressing the immediate crisis first, which can potentially prevent the escalation of bigger problems. Wanting to help clients solve all problems identified (Choice B) may not be feasible or necessary during a crisis situation where immediate intervention is crucial. Taking an active role in guiding the process (Choice C) is important, but the primary focus should be on crisis intervention. Feeling that work requires identification with all of a client's problems (Choice D) may lead to a lack of focus on the immediate crisis at hand.

3. In the context of milieu therapy, what is its primary purpose?

A. exploring the client's perception of reality
B. enhancing social interaction abilities
C. addressing maladaptive behaviors
D. providing routine daily experiences

Correct answer: D

Rationale: Milieu therapy aims to provide routine daily experiences to clients. By offering a structured and predictable environment, it helps individuals feel safe and secure, reducing disruptive behaviors. Exploring the client's perception of reality (choice A) may be part of therapy but not the primary focus. Enhancing social interaction abilities (choice B) and addressing maladaptive behaviors (choice C) are important aspects of therapy but not the primary purpose of milieu therapy.

4. How can medication bound to protein affect drug availability?

A. enhanced drug availability
B. rapid distribution of the drug to receptor sites
C. less availability to produce desired medicinal effects
D. increased metabolism of the drug by the liver

Correct answer: C

Rationale: Medication bound to protein reduces the availability of the drug to produce desired medicinal effects because only unbound drugs can effectively bind to active receptor sites. When a drug is bound to protein, it cannot bind with receptor sites, limiting its therapeutic impact. Choice A is incorrect because drug availability is reduced when it is bound to protein. Choice B is incorrect as rapid distribution to receptor sites is not possible if the drug is bound to protein and cannot bind with receptors. Choice D is incorrect as metabolism does not increase when the drug is bound to protein; the liver first needs to separate the drug from the protein before metabolism can occur.

5. A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. Which nursing action is most appropriate?

A. Reinsert the protruding organ and cover with 4x4s
B. Cover the wound with a sterile 4x4 and ABD dressing
C. Cover the wound with a sterile saline-soaked dressing
D. Apply an abdominal binder and manual pressure to the wound

Correct answer: B

Rationale: In the scenario where a client's wound eviscerates, the most appropriate nursing action is to cover the wound with a sterile saline-soaked dressing. Reinserting the protruding organ, as mentioned in choice A, is incorrect because it can lead to further complications requiring the client to return to surgery. Choice B, covering the wound with a sterile 4x4 and ABD dressing, is not ideal as it may not provide adequate protection and moisture for the exposed tissue. Choice D, applying an abdominal binder and manual pressure to the wound, is inappropriate as it does not address the specific needs of wound evisceration. Covering the wound with a sterile saline-soaked dressing helps maintain a moist environment, protects the exposed tissue, and prevents infection, promoting optimal wound healing and reducing the risk of complications.