NCLEX-PN EXAM PREP NEWEST ACTUAL EXAM QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES VERIFIED ANSWERS ALREADY 2024 UPDATE GRADED A+
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You are caring for a 14-month-old diagnosed with severe iron deficiency anemia. She is admitted for a blood transfusion and is started on oral iron supplementation. When you change her diaper, you note a dark black stool. What are the appropriate nursing actions? Select ALL A. Notify the healthcare provider. B. Document the finding. C. Continue with your assessment. D. Administer the oral iron supplement as prescribed - ANSChoices B, C, and D are correct. B is correct. Black stools are an expected response to iron supplementation. It is an appropriate nursing action to document this finding in the chart, but no further action is needed. C is correct. Black stools are an expected response to iron supplementation. It is an appropriate nursing action to continue with your assessment. Since the finding is expected, no other steps are necessary. D is correct. Black stools are an expected response to iron supplementation. It is an appropriate nursing action to administer the oral iron supplement as prescribed.
Choice A is incorrect. Black stools are an expected response to iron supplementation. The nurse doesn't need to notify the healthcare provider of this. NCSBN Client Need Topic: Physiological Integrity, Subtopic: Pharmacological therapies, Pediatrics Hematology
The nurse is re-educating on discharge instructions to a patient who has chronic diabetes insipidus (DI). Which of the following patient statements would indicate a correct understanding of the discharge instructions?
A. "I will need to drink no more than 800 ml per day." B. "I will need to weigh myself at the same time every day." C. "I should increase salty snacks in my diet." D. "I need to log my fluid intake and urine output." - ANSChoice B is correct. A patient with chronic diabetes insipidus (DI) is instructed to weigh themselves daily. This weight should be taken with the same scale and obtained after the first-morning void. Choices A, C, and D are incorrect. Fluid restrictions would be appropriate for a patient with syndrome of inappropriate antidiuretic hormone (SIADH). This would not be appropriate for DI as the patient will need to consume more fluids to replace those that are lost. Salty snacks are not encouraged
because this may hasten the hypernatremia associated with this disease. Logging intake and output are not useful because this provides a crude way of assessing fluid status.
This nurse is caring for a patient who is receiving prescribed ketorolac. Which of the following findings would indicate a therapeutic response? Select all that apply.
A. Decreased pain B. Increased urinary output C. Decreased blood pressure D. Decreased temperature E. Increased muscle coordination - ANS-Choices A and D are correct Ketorolac is a medication used to treat pain and pyrexia. A patient exhibiting a decrease in pain and having a decrease in temperature would be a therapeutic response. Choices B, C, and E are incorrect. Ketorolac does not therapeutically lower blood pressure, increase urinary output, or increase muscle coordination. Medications that could be used to lower blood pressure would be agents such as lisinopril, atenolol, etc. Agents used to increase urinary
output would be diuretics such as furosemide. The improvement in muscle coordination may be achieved by medications such as levodopa-carbidopa.
Which of the following falls under the right time of the 8 rights of medication administration? Select all that apply.
A. Have a second nurse independently calculate the medication dosage. B. Double-check the last time that the medication was administered. C. Verify the frequency with which the medication is ordered. D. Document the pertinent vital signs. - ANS-Choices B and C are correct. B is correct. Double-checking the last time the medication was administered is a part of the right time step in the 8 rights of medication administration. This is important because the nurse needs to verify that she is giving the dose correctly and that it is not being administered too frequently based upon the previous administration. C is correct. Verifying the frequency with which the medication is ordered is a part of the right time step in the 8 rights of medication administration. The nurse needs to [Show Less]