NCLEX Passpoint Exam (Latest 2024/ 2025 Update) With Questions and Verified Answers| | 100, Exams of Nursing

Download NCLEX Passpoint Exam (Latest 2024/ 2025 Update) With Questions and Verified Answers| | 100 and more Exams Nursing in PDF only on Docsity! NCLEX Passpoint Exam (Latest 2024/ 2025 Update) With Questions and Verified Answers| | 100% Correct | Grade A+ An adolescent is brought to the emergency department (ED) after accidentally taking an overdose of heroin. The adolescent is semiconscious, unable to respond appropriately to questions, slurs words, and has constricted pupils; the client's vital signs are blood pressure 60/50 mm Hg, pulse 50 beats/min, and respirations 8 breaths/min. Naloxone is administered to temporarily reverse the effects of the heroin. Which finding would first indicate that the naloxone administration has been effective? - ✔✔The client's respirations improve to 12/min; Decreased respirations and coma are the two most dangerous effects of heroin overdose, so an increase in respirations after administration of the naloxone demonstrates initial effectiveness of the medication. Changes in cognition and psychomotor activity will take more time to become apparent. The client's blood opioid level may not drop to a nontoxic level for a few days. The third stage of labor ends - ✔✔after the delivery of the placenta; The definition of the third stage of labor is the delivery of the placenta. The first stage of labor ends with complete cervical dilation and effacement. The second stage of labor ends with the birth of the neonate. The fourth stage of labor includes the first 4 hours after birth. The client with a nasogastric (NG) tube has abdominal distention. What should the nurse do first? You Selected: - ✔✔Check the function of the suction equipment; When a client with a NG tube exhibits abdominal distention, the nurse should first check the suction machine. If the suction equipment is functioning properly, then the nurse should take other steps, such as repositioning the tube or checking tube patency by irrigating it. If these steps are not effective, then the HCP should be called. A public health nurse has been asked to teach the importance of hand washing to elderly clients. Which statement by a client indicates that the teaching has been effective? - ✔✔Friction while washing hands decreases transmission of bacteria; Soap helps by reducing surface tension of water, but friction is necessary for the removal of microorganisms. The use of warm water still needs friction. Use of other products besides soap can reduce infection. Fifteen seconds is an insufficient length of time for hand washing. A client develops hepatic encephalopathy 1 week after portal caval shunt surgery. The client's physician orders neomycin, 4 g by mouth daily in four divided doses. The client's partner asks how neomycin decreases the serum ammonia concentration. How should the nurse respond? - ✔✔Neomycin decreases the amount of ammonia-producing bacteria in the GI tract; Neomycin lowers the blood ammonia level by reducing the quantity of ammonia-producing bacteria in the GI tract. The drug also exerts its antibacterial activity directly on the ribosomes of susceptible organisms, among them E. coli, by inhibiting protein synthesis via direct action on ribosomal subunits. When present, these bacteria convert urea to ammonia. Neomycin is bactericidal in high concentrations and bacteriostatic in low concentrations. Thus, it doesn't trap or bind with ammonia in the GI tract. A hospital safety officer is evaluating nurses' responses to potential safety hazards. Which employee actions are appropriate for the situation? Select all that apply. - ✔✔1. taking small steps with feet shoulder length apart when walking on wet surfaces 2. removing clients from the area where a fire is reported 3. using tongs to place a dislodged radioactive device in a lead container A client with chronic obstructive pulmonary disease presents with respiratory acidosis and hypoxemia. The client tells the nurse that they don't want to be placed on a ventilator. What action should the nurse take? - ✔✔Notify the physician immediately to have the physician determine client competency; Three requirements are necessary for informed decision-making: the decision must be given voluntarily; the client making the decision must have the capacity and competence to understand; and the client must be given adequate information to make the decision. In light of the client's respiratory acidosis and hypoxemia, the client might not be competent to make this decision. The physician should be notified immediately so the physician can determine client competency. The physician, not the nurse, is responsible for discussing the implications of a DNR order with the client. The Patient's Bill of Rights entitles the client to make decisions about the care plan, including the right to refuse recommended treatment. The client's family may oppose the client's decision. Consulting the palliative care group isn't appropriate at this time and must be initiated by a physician order. A client in the emergency department reported vomiting and diarrhea for the previous 24 hours. The client's blood pressure is 90/60 mm Hg, respiration is 20 breaths per minute, heart rate is 92 beats per minute, and temperature is 37.5° C (99.5° F). Which intervention will the nurse perform first? - ✔✔Assess for dehydration; The priority for this client is assessing the problem. Then the nurse should treat the fluid volume deficit, then the temperature. This client has hypotension, and the nurse would raise the legs, not the head, of the bed first to improve perfusion to the brain, as it is the least restrictive intervention. A nurse is caring for a client who has returned to their room after a carotid endarterectomy. Which action should the nurse take first? - ✔✔Ask the client if they have trouble breathing; The nurse should first assess the client's breathing. A complication of a carotid endarterectomy is an incisional hematoma, which could compress the trachea causing breathing difficulty for the client. Although the other measures are important actions, they aren't the nurse's top priority. A client has been unable to void since having abdominal surgery 7 hours ago. What should the nurse do first? - ✔✔Assist the client up to the toilet to attempt to void; Urinary retention is common following abdominal surgery. The nurse should first assist the client to an anatomically comfortable position to void prior to resorting to other strategies such as cauterization. If the client is unable to void, the nurse can use a bladder scanner to determine the volume of retained urine, and then, if necessary, use an intermittent urinary catheter. While increasing fluid intake is important, it will not help the client void now. An 8-year-old has a body mass index (BMI) for age at the 90th percentile but has no other risk factors. What should the nurse do? - ✔✔Refer the family to a dietician; Children aged 2 to 20 years with a BMI- for-age at the 90th percentile are considered overweight. If no other risk factors are present, the family should receive dietary counseling to slow the child's weight gain until an appropriate height for weight is attained. Without intervention, the child may become obese. An HCP who specializes in pediatric weight loss should be considered when the child is obese and has complicating factors. Commercial diet programs alone do not include the necessary monitoring for children, thus are rarely appropriate. The health care provider prescribes raloxifene hydrochloride for a 60-year-old woman. The drug is effective if the client does not develop: - ✔✔Osteoporosis; Raloxifene hydrochloride, an estrogen receptor modulator, increases bone mineral density without stimulating the endometrium. The drug is useful in preventing osteoporosis in postmenopausal women. This drug is contraindicated for women who smoke cigarettes or who have a history of venous thrombosis. Raloxifene does not prevent hot flashes or hyperglycemia. One of its adverse effects is increased headaches. A 12-year-old client needs lifesaving emergency surgery, but the relatives live an hour away from the hospital and cannot sign the consent form. What is the nurse's best response? - ✔✔Call the family for a consent over the telephone, and have another nurse listen as a witness; While laws in states and provinces may vary, generally, when the client cannot sign the operative consent and it is a true life- saving emergency, consent may be obtained over the telephone from the client's next-of-kin or guardian. The surgeon must obtain the telephone consent, but if it is a true life-saving emergency the surgeon often is already in surgery, so the nurse makes the telephone call and another nurse witnesses the call. Some institutions have a special consent form for emergency surgery. Consent can be waived in situations in which no family is available; however, if the family can be reached by telephone before surgery, verbal consent is legally required. Which of the following situations does the nurse recognize as having the greatest risk for the fetus? - ✔✔a fundal height of 27 cm at 32 weeks gestation; Optimal fetal growth and development during pregnancy are assessed with fundal height measurement. Fundal height, measured in centimeters, should equal gestational weeks throughout the pregnancy (e.g., fundal height of 27 cm should occur at 27 weeks gestation). A fundal height of 27 cm at 32 weeks gestation is a very ominous finding that requires immediate attention and investigation. The fetal heart rate (FHR) range is 110-160 bpm but may fluctuate with fetal movement. It is considered tachycardia and at risk only if a FHR is greater than 160 bpm for at least 10 minutes. A breech lie may result in a cesarean section, which carries increased risk after childbirth. There is a possibility that the fetus will change the lie naturally prior to birth or an external cephalic version may be performed. A gestation of 37 completed weeks is considered term. After a third arrest for abusing a neighbor's cat, a client is admitted to the psychiatric unit for treatment of antisocial personality disorder. This client has a history of conduct disorder. Which action is most appropriate for the nurse assigned to this client? - ✔✔examining personal feelings toward the client; When caring for a client with a personality disorder, a nurse must examine personal feelings toward the client. If the nurse has negative feelings about the client, the client will sense this and may "act out" the feelings. Also, conveying negative feelings could jeopardize the therapeutic relationship. Clients with antisocial personality disorder aren't motivated to problem-solve because they lack remorse and have no regard for the truth. Although the nurse must set strict limits on manipulative behavior, insisting that the client obey all unit rules and attend all unit activities would make the client feel increasingly threatened. Drug therapy is rarely effective in treating personality disorders, except in cases of extreme distress such as severe anxiety (which this client doesn't exhibit). What are important nursing care measures for a client with diabetes who is admitted with end-stage renal failure? - ✔✔Restrict sodium and potassium and restrict fluids as ordered; In renal failure, there is retention of sodium and potassium, so these are restricted. Important care measures will also include fluid restrictions. The client will require permanent dialysis, not temporary as with acute renal failure. The diet will be restricted in protein to decrease waste products. Hypertension is associated with chronic renal failure. A nurse is caring for four clients who gave birth 12 hours ago. Which client is at greatest risk for complications? - ✔✔gravida 2 para 2002, cesarean birth, incision site intact, hemoglobin level 9.8 g/dl; Women who have anemia during pregnancy (defined as a hemoglobin less than 10 g/dl) may experience more complications such as poor wound healing and inability to tolerate activity. An intact incision site and a pulse of 84 beats/minute after a cesarean birth and a temperature of 99.8° F (37.7° C) after a vaginal delivery with episiotomy are findings within normal limits. Dehydration can cause a slightly elevated temperature. Although women whose membranes are ruptured more than 24 hours before birth are more prone to developing chorioamnionitis, the client with anemia is at greater risk for complications. Two days following abdominal surgery, a client is refusing to take a narcotic pain medication, even though the pain rating is an 8 on a 0 to 10 scale. The client tells the nurse, "I don't want to get dependent on that stuff." Which response from the nurse is the most appropriate? - ✔✔"You will recover more quickly and more effectively if you take pain medication now;" Common client misconceptions regarding pain and pain medication administration include a concern that taking pain medication regularly will lead to addiction. However, this misconception overstates the risk of addiction and greatly understates the risk of immobility due to poor pain control, including atelectasis, decubitus formation, and delayed healing. The nurse should assist the client to understand the importance of adequate pain medication to support and promote client mobilization following surgery and client/family satisfaction with care. There is a potential for dependence and addiction with all narcotic drugs, although this is not likely during the postoperative period. The nurse reviews a client's lab values and implements which intervention to help with maintenance of skin integrity? - ✔✔Begin infusion of intravenous fluids; A client with an increased sodium level potentially has dehydration, which can impact skin integrity as a risk factor. Beginning rehydration through the infusion of intravenous fluids will help with restoring fluid volume, and preventing dry skin. The WBC count is still within normal limits, so monitoring the temperature is not indicated. While the potassium level is decreased and the client may need cardiac monitoring, this does not have an effect on skin integrity. Nutrition does have an effect, but there is no indication of the client being malnourished with a glucose level of 111 mg/dL. A laboring client provides the nurse with the birth plan that she wishes to follow. The birth plan expresses that the client wishes for her partner to do the coaching through her contractions. What is the best way for the nurse to meet this family's needs during labor and birth? - ✔✔Enter the birthing room as few times as possible to do the required assessments; The birth plan is a vehicle for communicating to the healthcare providers the family's desires regarding the birth attendant; birth setting; support person; and activities during labor, birth, and the postpartum period. The nurse should collaborate with the couple to respect their plans and privacy while achieving the goals of safe childbirth. It is incorrect to contact the physician; the plan should be discussed directly with the couple to ensure understanding of their desires. It is critical that the nurse does enter the room to perform the required assessments, and not only when requested, to ensure safety of both mother and baby. After teaching the client about lochia, the nurse determines that the client understands the instructions when she says that on the 10th or 11th postpartum day, the lochia should be which color? - ✔✔White; About the 10th day after childbirth, the discharge becomes thin, scanty, and almost without color (white). At this time, it is called lochia alba. The vaginal discharge from approximately day 4 through day 9 becomes more serous and watery, pink to pinkish or brown in color. At this time, it is called lochia serosa. The vaginal discharge that normally occurs for 2 to 3 days after childbirth, lochia rubra, contains mostly blood and is dark red in color. A brown vaginal discharge is commonly associated with lochia serosa, the vaginal discharge from approximately day 4 through day 9. The emergency room nurse is caring for a client who fell, breaking the tibia. The nurse determines that the client understands the risk of compartment syndrome when knowing to report which early symptom nurse should give the client milk and a graham cracker with peanut butter or a glass of orange juice after confirming the low glucose level. It isn't necessary to notify the physician or to obtain a serum glucose level at this time. A nurse is planning staffing for a nursing unit in which the primary need of the clients is learning how to manage their health problems. Which combination is the ideal mix of staff for this unit? - ✔✔three registered nurses (RNs); The ideal staffing for a nursing unit focused on client teaching and learning is to have three registered nurses. It is within the scope of practice for the RN to assess, plan, implement, coordinate, and evaluate client learning. It is not within the scope of practice for LPNs/VNs and UAP to provide client teaching. For which medication(s) will the nurse ask another nurse to witness the disposal of a partial dose in the phamaceutical waste container? Select all that apply. - ✔✔alprazolam hydrocodone meperidine; Federal law requires two nurses to witness and document the waste of all controlled subsatnces in order to prevent diversion and misuse of these substances. Alprazolam, hydrocodone, and meperidine are controlled substances. These medications require the nurse to have another nurse witness the waste in a pharmaceutical waste container. Losartan and amlodipine are not controlled substances and do not require special procedures for the waste of a partial dose. An Asian-American client with hyperglycemia is admitted to the healthcare facility. After the client is stable, the nurse discovers that the client has not had the prescribed medicines. The client believes that eating saffron will keep blood glucose level under control. The nurse determines that saffron is not known to influence blood glucose levels. What is the most appropriate response by the nurse? - ✔✔"Why don't you take the medicines, too, and benefit from both?" Although the nurse may disagree with the client's beliefs concerning the cause of health or illness, respect for these beliefs helps the client to achieve healthcare goals. Asking the client to consider the benefits of medicine is appropriate, because the nurse, without disrespecting the client's beliefs, persuades the client to have medicines also. The nurse saying that saffron does not have any effect on blood glucose level is inappropriate because it disregards the client's beliefs. The nurse's agreeing with the client may provide encouragement and indicate low faith in the present treatment. It is inappropriate to call the doctor and complain about the client. The nurse is preparing to administer medications to the client. Which identifiers will the nurse use? Select all that apply. - ✔✔wristband birthdate name The nurse is preparing to administer medications to a client through a nasogastric (NG) tube. What interventions should the nurse include in the client's plan of care? Select all that apply. - ✔✔1. Flush NG tube in between medications. 2. Position the client in a Fowler's position during feedings; Medications should be separated with 15 mL of NS or water in between. High Fowler's position prevents aspiration. Time-released medications should never be crushed. Medications should be given in separate syringes and residual contents should be returned. When caring for an oncology client receiving cisplatin and experiencing nausea and mouth sores, which nursing interventions are best to improve the client's diet? Select all that apply. - ✔✔1. Schedule high- nutrient shakes between meals. 2. Offer small, frequent, light meals 5-6 times daily. 3. Administer oral anesthetic 15 minutes prior to meals. 4. Offer cool drinks and foods as tolerated; Optimal nutrition includes a balance of protein, carbohydrate, and only a small amount of fat. A client on cisplantin commonly has additional side effects of nausea and oral sores. Changes in the plan of care include high-nutrient shakes to compensate for low oral intake. Eating smaller, light meals commonly cooler in temperature as opposed to hot meals are better tolerated. Offering an oral anesthetic prior to meals decreases discomfort in the eating process. Large meals that are spicy and high in fat are discouraged. An older adult is being discharged following a repair of an inguinal hernia. The client is independent and lives alone, but the client's family lives 60 miles from the client's house. When at home, the client is to cleanse and inspect the incision for signs of infection. The client and family are able to read and understand written instructions. When giving discharge instructions, what should the nurse do? Select all that apply. - ✔✔1. Explain the instructions to the client. 2. Ask the client to demonstrate the procedure. 3. Provide written instructions for the client. The nurse should explain and demonstrate the discharge instructions and then ask the client to give a return demonstration. The Joint Commission and Health Canada require that discharge instructions be written for the postoperative client. Clients need to be given discharge instructions orally and in written form because of stress, medications, and the volume of material to be learned. Explaining all the instructions to family members and giving them a link to a video is important but does not replace the need for written instructions. Since the family does not live nearby, the nurse must be certain the client can manage the instructions alone. When developing a nutritional plan for a child who needs to increase protein intake, the nurse should suggest which foods? Select all that apply. - ✔✔cooked dry beans peanut butter yogurt A client recently had a right total hip replacement. As a result of intraoperative blood loss, postoperative serum hemoglobin levels and hematocrit are low. The physician orders two units of packed red blood cells. During the infusion of the first unit of blood, the client develops a transfusion reaction and experiences urticaria, itching, and bronchospasm. The nurse discontinues the transfusion and notifies the physician. Which antihistamine does the nurse anticipate administering to treat this type I hypersensitivity reaction? - ✔✔chlorpheniramine maleate; The parenteral form of chlorpheniramine maleate is used to relieve symptoms of anaphylaxis and allergic reactions to blood or plasma. Tripelennamine citrate, astemizole, and cyclizine aren't used to treat blood transfusion reactions. Parents bring a child to the clinic who has not been eating or drinking well for the last few days. What action should the nurse take first to assess the child's overall hydration status? - ✔✔Weigh the child; When implementing nursing care, the nurse should complete any noninvasive procedures before invasive ones. Therfore, the first step the nurse should take is to weigh the child. A decrease in body weight gives the most accurate information about the infant's hydration status. Monitoring vital signs would be the next step in the assessment process. The blood pressure reading would yield information about hypotension. A urinalysis would provide information about urine osmolality and specific gravity of the urine, which indicates dehydration. Obtaining electrolytes would provide information about electrolyte disturbances, not strictly about hydration. A client with colon cancer had a left hemicolectomy 3 weeks ago. The client is still having difficulty maintaining an adequate oral intake to meet metabolic needs for optimal healing. The nurse should recommend to the health care provider which nutritional support to maintain the nutritional needs of the client? - ✔✔total parenteral nutrition through a central catheter; Total parenteral nutrition solutions supply the body with sufficient amounts of dextrose, amino acids, fats, vitamins, and minerals to meet metabolic needs. Clients who are unable to tolerate adequate quantities of foods and fluids and those who have had extensive bowel surgery may not be candidates for enteral feedings. The nurse would anticipate total parenteral nutrition via central catheter to promote wound healing. IV dextrose does not supply all the nutrients required to promote wound healing. A pregnant client presents to the emergency department with complaints of back pain. This is the second visit in a month. She is accompanied by her spouse, who refuses to let the client speak for herself. When inspecting the painful area, the nurse notes bruising on the client's lower back. The client's spouse states that the client is clumsy and falls down the front steps of the house often. What should the nurse do first in this situation? - ✔✔Separate the pregnant client from her partner; The possibility of violence should be considered when there are injuries to the client and a reported history that is not consistent with the actual presenting problems. If abuse is suspected, immediately isolate the paternalism when a client's loss of consciousness or other circumstances compel them to decide what is best for the client and to act without consulting the individual. Beneficence means that nurses should act in the client's interests always. Fidelity requires the nurse to be faithful and truthful and to keep promises to clients, families, coworkers, and employers. Autonomy refers to every individual's right to make rational decisions about their life. The nurse's belief in autonomy leads to a respect for the client's decisions. A client is experiencing intertrigo caused by friction between the inner thighs. Which action should the nurse take to help this client? - ✔✔Apply lubricating lotion over the affected areas; Friction between the inner thighs can be reduced by applying a lubricant over the affected areas. An antihistamine would be used for an allergic reaction. Because there is no evidence that the affected area was caused by a fungus, an antifungal agent would not be appropriate. Warm soaks may cause further irritation to the affected skin areas and should not be used A 36-year-old client is admitted with a possible ruptured ectopic pregnancy. The nurse should prepare the client for which procedure? - ✔✔ultrasound; Symptoms of ruptured ectopic pregnancy are not always obvious. If bleeding into the pelvic cavity is extensive, then vaginal examination causes intense pain. Ultrasound will detect the location of rupture and bleeding, thus confirming the diagnosis. Dilation and curettage is indicated for a missed or incomplete abortion, not for a ruptured ectopic pregnancy. The uterus is not evacuated because the pregnancy is located outside the uterus. Oophorectomy (removal of the ovaries) is usually not performed, although a salpingectomy (removal of the tube) or salpingostomy (removal of the conceptus) is often performed to prevent further bleeding. A postpartum client decides to bottle-feed her neonate. Which client statement indicates the need for further teaching about preventing engorgement? - ✔✔Taking hot showers can help reduce engorgement" This client demonstrates a need for futher teaching when she states that hot showers can help reduce engorgement. Hot showers actually stimulate the breasts, triggering milk production and prolonging the discomfort of engorgement. The client is correct in stating that she shouldn't express milk manually because doing so can also trigger milk production. Antilactation drugs are no longer recommended because a rebound effect may occur after they're discontinued; also, they're expensive and may cause adverse effects. The proper brassiere does help prevent breast engorgement by providing support and acting as a barrier to breast stimulation. The nurse is assessing with a head injury a client for decerebrate posturing. Which position indicates the client has decerebrate posturing? - ✔✔back arched, rigid extension of all four extremities; Decerebrate posturing occurs in clients with damage to the upper brain stem, midbrain, or pons and is demonstrated clinically by arching of the back, rigid extension of the extremities, pronation of the arms, and plantar flexion of the feet. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers describes decorticate posturing, which indicates damage to corticospinal tracts and cerebral hemispheres. A client with decreased urine output refractory to fluid challenges is evaluated for renal failure. Which condition may cause the intrinsic (intrarenal) form of acute renal failure? - ✔✔nephrotoxic injury secondary to use of contrast media; Intrinsic renal failure results from damage to the kidney, such as from nephrotoxic injury caused by contrast media, antibiotics, corticosteroids, or bacterial toxins. Poor perfusion to the kidneys may result in prerenal failure. Damage to the epithelial cells of the renal tubules results from nephrotoxic injury, not damage to the adrenal cortex. Obstruction of the urinary collecting system may cause postrenal failure. A nurse is caring for a 16-year-old girl who isn't sexually active. The girl asks if she needs a Papanicolaou (Pap) test. How should the nurse respond? - ✔✔"No, it isn't necessary because you aren't sexually active." A client hospitalized for preterm labor tells the nurse that she's having occasional contractions. Which nursing intervention would be the most appropriate? - ✔✔Encourage the client to empty her bladder, give I.V. fluids, and encourage oral fluids. A nurse is assessing a client who is being abused. The nurse should assess the client for which characteristic(s)? Select all that apply. - ✔✔self-blame alcohol abuse suicidal thoughts guilt A nurse can auscultate for heart sounds more easily if the client is - ✔✔leaning forward; The nurse can best auscultate for heart sounds by asking the client to lean forward and exhale forcefully. This position enables the nurse to listen for heart sounds without the sound of expiration interfering. Using the supine position to visually inspect the precordium allows the nurse to observe the chest wall for movement, pulsations, and exaggerated lifts or strong outward thrusts over the chest during systole A nurse is teaching a client about metformin therapy. The nurse warns the client that metformin commonly causes hypoglycemia when combined with which other medication? - ✔✔ACE inhibitors A client who is taking aspirin caplets develops prolonged bleeding from a superficial skin injury on the forearm. The nurse should tell the client to do which action first? - ✔✔Apply an icepack for 20 min A registered nurse is mentoring a new graduate nurse. Which action by the new graduate demonstrates a need for further teaching? - ✔✔turns the defibrillator to synchronize before defibrillating a client with ventricular fibrillation; The synchronizer switch should be turned "off" when defibrillating. All other answers are correct and do not require further teaching. A hospital is changing the format for documentation in an attempt to decrease the time the nurses are spending on charting. The new type of charting will require that nurses document the significant findings as a narrative note in a shorthand method using well-defined standards of practice. Which best defines this type of charting? - ✔✔Charting by exeption A client is admitted with a suspected abruptio placentae. The nurse should assess the client for which signs and symptoms? Select all that apply. - ✔✔bleeding that is concealed or apparent, abdominal rigidity, painful abdomen A client with diabetic ketoacidosis was admitted to the intensive care unit 4 hours ago and has these laboratory results: blood glucose level 450 mg/dl, serum potassium level 2.5 mEq/L (2.5 mmol/L), serum sodium level 140 mEq/L 140 mmol/L), and urine specific gravity 1.025. The client has two I.V. lines in place with normal saline solution infusing through both. Over the past 4 hours, the client's total urine output has been 50 ml. Which physician order should the nurse question? - ✔✔Change the second I.V. solution to dextrose 5% in water; The nurse should question the physician's order to change the second I.V. solution to dextrose 5% in water. The client should receive normal saline solution through the second I.V. site until the client's blood glucose level reaches 250 mg/dl. The client should receive a fluid bolus of 500 ml of normal saline solution. The client's urine output is low and their specific gravity is high, which reveals dehydration. The nurse should expect to hold the insulin infusion for 30 minutes until the potassium replacement has been initiated. Insulin administration causes potassium to enter the cells, which further lowers the serum potassium level. Further lowering the serum potassium level places the client at risk for life-threatening cardiac arrhythmias. The nurse is assigning a room for a client admitted with hepatitis A. Which diagnosis would be an appropriate roommate for this client? - ✔✔Congestive heart failure