"A patient with end-stage renal disease has a potassium level of 7.5 mEq/l. Based on this laboratory result, the nurse interprets which symptom as significant prompting which action?
a. Drowsiness, stimulate the patient every 30 minutes
b. Confusion, ask the patient to state their name and date of birth
c. Irregular heartbeat, evaluate the patient's capillary refill
d. Muscle cramps, elevate the affected limb"
The above question in italics addresses which category of the NCLEX-RN® test plan and which level of Bloom's taxonomy?
a. Physiologic adaptation, application level
b. Pharmacologic and parental therapy
c. Integrated processes
d. Basic care
ANS: A
Correct: It is important to remember that candidates have specified laboratory values for which they must know the normal range and clinical manifestations when values are high, low, or critical. This question addresses an alteration in body system homeostasis. The student must know the normal lab value for potassium and common symptoms, as well as the correct nursing action.
Incorrect:
b. No pharmacologic therapy was administered.
c. Integrated processes include therapeutic communication and caring, which is not tested.
d. Practices to promote rest and sleep fall under basic care (14%).
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A patient has a nursing diagnosis of "Noncompliance with medication regimen related to a belief that God will heal her and that it would show a lack of faith to take the medications."
The nurse and a clergyman have spent some time discussing spiritual and treatment issues with the patient. Which of the following would indicate that progress is being made toward achieving compliance with health care therapy? (Choose all that apply.) The patient says: 1) "I will try to pray more often for stronger faith that God will heal me." 2) "Let me think about it until tomorrow; I may see my way to taking those pills then." 3) "You know, I've known some very holy people who were not cured by God." 4) "There is no confusion in my mind as to the right thing for me to do."
In evaluating the effectiveness of an exercise program in an obese client, the nurse should expect the following outcomes:
A) reduced bone density. B) reduced insulin sensitivity. C) increased joint pain. D) enhanced feelings of well-being.
A patient is being treated for an aneurysmal subarachnoid hemorrhage (SAH) that occurred 10 days ago
The nurse recognizes that the patient is at risk for decreased cerebral blood flow and is especially concerned when which assessments are made? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. The patient seems unable to verbalize needs. 2. The patient has difficulty starting the flow of urine. 3. The patient reports a stiff neck. 4. The patient has a temperature of 101°F. 5. The patient has unequal but reactive pupils.