NLN NACE Prep Latest Update 2024 -2025 Actual Exam 160 Questions and 100% Verified C orrec t Answers A 23 year old woman who has pheylketonuria(PKU) and has not been on a PKU diet since adolescence tells the nurse that she wants to become pregnant. In order to respond appropriately to this client, the nurse must understand...... - CORRECT ANSWER: High phenylalanine levels impair fetal development -the fetus would be at risk delayed development, mental retardation, poor head growth (microcephaly), poor overall growth, heart defects, and other structural birth defects -the closer to normal levels in the blood plasma the less likely complications A 31 year old client is receiving medical treatment for ulcerative colitis. The treatment includes antibiotics and prednisone. A nurse should plan to monitor the client for which nutritional consequence of this treatment? - CORRECT ANSWER: Hyperglycemia -prednisone provides amino acids and glycerol gluconeogenesis by diminishing glucose utilization, increase protein breakdown, and activating lipolysis in the periphery resulting in an increase in blood glucose concentrations A 9year old child who began taking methylphenidate hydrochloride (Ritalin) one year ago appears to have slowed growth. What assessment would best reveal an explanation for the growth pattern? - CORRECT ANSWER: Diet history -helps the nurse gather information and background data A client has a nursing diagnosis of fluid volume excess. Following effective treatment the nurse should expect what outcome? - CORRECT ANSWER: Decrease in pedal edema, pulse rate, clear lung sounds, an increase in urine output A client has an order for a transdermal nitroglycerin(Nitro -Dur) patch q6h. What action should the nurse include when applying a new patch? - CORRECT ANSWER: Rotate application sites A client has ingested a toxic dose of acetaminophen. A nurse should expect alteration in what lab values? - CORRECT ANSWER: Serum bilirubin -Tylenol can cause liver failure A client in ICU is being closely monitored after a fall. The nurse notices a slight increase in ICP. The nurse should intervene by...... - CORRECT ANSWER: Increase oxygen flow - because hypoxia can worsen iCP -DO NOT RAISE HOB, REPOSITION, OR SUCTION THE PATIENT because it can increase ICP A client is receiving intermittent nasogastric tube feedings. A nurse should aspirate the residual stomach contents prior to administering a scheduled feeding to..... - CORRECT ANSWER: Determine absorption of feedings A client is to be checked for residual urine. At which time should the procedure be performed? - CORRECT ANSWER: Immediately after the client voids A client was found unconscious and has a blood pressure of 70/35. What medication would the nurse administer? - CORRECT ANSWER: Atropine sulfate (atropine) A client who appears cachetic is scheduled for emergency surgery. A preoperative nutritional assessment should be performed for what reason? - CORRECT ANSWER: A malnourished client is prone to postoperative infection A client who has a diagnosis of diabetes reports diarrhea. When assessing the clients diet for a possible cause of the problem, a nurse should determine is consuming what substance? - CORRECT ANSWER: Sorbitol - consumed in large amount can lead to some abdominal pain, gas, and mild to severe diarrhea A client who has been diagnosed with insulin -dependent diabetes mellitus reports feeling hypoglycemic every day after practicing with their team. What recommendation by the nurse would help prevent this occurence? - CORRECT ANSWER: Eat an extra bread exchange an hour before practice -Ex. whole grains, most unprocessed foods, and resistant starches -they deliver energy that is released slowly, providing moderate rises in the body's blood sugar levels, which helps to avoid low energy crashes and maintain greater energy control throughout the day A client who has COPD uses oxygen. A nurse should recognize that which measure would be a safety hazard? - CORRECT ANSWER: Using oxygen at 6L/min -the patients should maintain low flow oxygen rates because they have hypoxia and hypercarbia -increasing their oxygen can cause loss of respiratory drive and lead to respiratory arrest A client who has had a CVA has left -sided weakness. To help maintain the client's affected bodily structures in functional position, a nurse should use what article? - CORRECT ANSWER: A rolled washcloth in the palm of the clients left hand -prevents contractures A client who is jaundiced reports itching. To relieve the itching what measure would be most helpful - CORRECT ANSWER: Giving the client sponge baths with tepid water several times a day A client who is on prolonged bed rest should have a footboard for which purpose? - CORRECT ANSWER: To prevent paralysis of anterior leg muscles and retain normal functional position - wearing high topped sneakers does the same A client who is receiving continuous bladder irrigation has an intake of 800ml of intravenous fluid and 2000ml of irrigating solution. The urinary drainage bag contains 3800ml. What is the charted output? - CORRECT ANSWER: 1800ml -3800 -2000(irrigating solution)=1800ml A client who is suspected of having a hiatal hernia is admitted to the hospital. Which question is important for the nurse to ask? - CORRECT ANSWER: "Do you experience heartburn after a large meal?" -They need to eat small, frequent meals A client who is terminally ill with AIDS is admitted to the hospital. What precaution should be included in the client's plan of care? - CORRECT ANSWER: Standard Precautions A client who is using crutches reports pain and numbness in the Achilles. This report is most likely attributable to which of these causes? - CORRECT ANSWER: Incorrect weight bearing -Shouldn't lean on the crutches -arms should support weight - 3 finger distance should be kept between top of crutch and armpit A client with dumping syndrome should be instructed to limit intake of what food substances? - CORRECT ANSWER: Simple sugars - pass through stomach too quickly and may cause diarrhea and cramping A client's order reads: "Aspirin 650mg PO PC" When should the nurse give the aspirin? - CORRECT ANSWER: After meals -Aspirin irritates the stomach lining A female client asks a nurse about the benefits of estrogen replacement therapy(ERT). What response is appropriate? - CORRECT ANSWER: ERT decreases development of osteoporosis A nurse applies moderate heat to a client's abdomen for 20 minutes as prescribed. What effect should result? - CORRECT ANSWER: An increase in arterial blood flow -expands blood vessels A nurse discovers flames in a wastebasket in the room of a client who is a paraplegic. What action should the nurse take first? - CORRECT ANSWER: Rescue the client
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