Next Generation NCLEX (NGN) Fundamentals of Nursing, Study notes of Nursing

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Comprehensive NCLEX NGN Practice Questions for

FUNDAMENTALS OF NURSING

A Guide to Critical Thinking and Clinical Judgment

Table of Contents:

1. Introduction

o Overview of Next Generation NCLEX (NGN)

o Purpose of the eBook

o How to Use This eBook for Effective Study

o Key Concepts in Fundamentals of Nursing

2. Chapter 1: Nursing Assessment and Patient Safety

o Case Study: Diabetic Ketoacidosis (DKA) Management

o Extended Multiple Response: Warfarin Safety Precautions

o Highlight Text: Fall Prevention Strategies

o Cloze (Drop-Down): Identifying Postoperative Complications

o Matrix/Grid: Isolation Precautions and Client Conditions

3. Chapter 2: Fluid and Electrolyte Balance

o Case Study: Dehydration and Rehydration Therapy

o Extended Multiple Response: Managing Fluid Volume Excess

o Highlight Text: Identifying Signs of Hypokalemia

o Cloze (Drop-Down): Assessing Fluid Volume Status

o Matrix/Grid: Electrolyte Imbalances and Nursing Interventions

4. Chapter 3: Cardiovascular Nursing Care

o Case Study: Hypertensive Crisis Management

o Extended Multiple Response: Nursing Interventions for Heart Failure

o Highlight Text: Medication Adherence in Hypertension

o Cloze (Drop-Down): Reducing Cardiac Workload Post-MI

o Matrix/Grid: Cardiovascular Conditions and Nursing Interventions

5. Chapter 4: Respiratory Management

o Case Study: COPD Exacerbation and Oxygen Therapy

o Extended Multiple Response: Care Plan for Clients with Pneumonia

o Highlight Text: Proper Use of Metered-Dose Inhalers (MDIs)

o Cloze (Drop-Down): Identifying Respiratory Therapy Complications

o Matrix/Grid: Respiratory Therapies and Nursing Interventions

6. Chapter 5: Gastrointestinal and Nutritional Nursing

o Case Study: Acute Pancreatitis Management

o Extended Multiple Response: Dietary Modifications for Gout

o Highlight Text: GERD Lifestyle Modifications

o Cloze (Drop-Down): Iron Supplementation in Anemia

o Matrix/Grid: GI Conditions and Dietary Interventions

7. Chapter 6: Pain Management and Neurological Nursing

o Case Study: Acute Pain Management Post-Surgery

o Extended Multiple Response: Non-Pharmacological Pain Management

o Highlight Text: Managing Chronic Back Pain

o Cloze (Drop-Down): Neurological Assessment for Stroke

o Matrix/Grid: Neurological Conditions and Nursing Interventions

8. Chapter 7: Endocrine and Metabolic Disorders

o Case Study: Hyperthyroidism and Symptom Management

o Extended Multiple Response: Dietary Recommendations for Diabetes

o Highlight Text: Recognizing Hypoglycemia

o Cloze (Drop-Down): Nursing Interventions for Hyperglycemia

o Matrix/Grid: Endocrine Disorders and Nursing Care

9. Chapter 8: Skin and Wound Care

o Case Study: Pressure Ulcer Prevention and Management

o Extended Multiple Response: Eczema Skin Care Instructions

o Highlight Text: Wound Care for Diabetic Ulcers

o Cloze (Drop-Down): Recognizing Wound Infection

o Matrix/Grid: Types of Wounds and Appropriate Care

10. Chapter 9: Renal and Urinary Nursing Care

o Case Study: Chronic Kidney Disease and Fluid Management

o Extended Multiple Response: UTI Prevention Strategies

o Highlight Text: Care for Clients with Indwelling Catheters

o Cloze (Drop-Down): Managing Urinary Retention

o Matrix/Grid: Urinary Disorders and Nursing Interventions

11. Chapter 10: Mobility, Safety, and Patient Education

o Case Study: Fall Risk Assessment and Prevention

o Extended Multiple Response: Mobility Interventions for Older Adults

o Highlight Text: Safe Use of Mobility Aids

o Cloze (Drop-Down): Postoperative Mobility and Safety

o Matrix/Grid: Mobility Conditions and Safety Interventions

12. Chapter 11: Postoperative and Perioperative Nursing Care

o Case Study: Pain Management After Abdominal Surgery

o Extended Multiple Response: Preoperative Teaching Points

o Highlight Text: Postoperative Complications and Early Signs

o Cloze (Drop-Down): Monitoring Postoperative Patients

o Matrix/Grid: Surgical Interventions and Nursing Care

13. Chapter 12: Pharmacology in Nursing Practice

o Case Study: Safe Administration of Opioid Analgesics

o Extended Multiple Response: Nursing Responsibilities with Anticoagulants

o Highlight Text: Understanding Medication Interactions

o Cloze (Drop-Down): Managing Side Effects of Antihypertensives

o Matrix/Grid: Drug Classifications and Nursing Implications

14. Chapter 13: Psychosocial Integrity and Patient-Centered Care

o Case Study: Therapeutic Communication with Anxious Clients

o Extended Multiple Response: Addressing Patient Coping Mechanisms

o Highlight Text: Educating Clients on Mental Health Resources

o Cloze (Drop-Down): Managing Clients with Behavioral Health Conditions

o Matrix/Grid: Psychosocial Nursing Interventions and Patient Outcomes

15. Chapter 14: Infection Control and Hygiene

o Case Study: Preventing Healthcare-Associated Infections (HAIs)

o Extended Multiple Response: Best Practices for Hand Hygiene

o Highlight Text: Implementing Standard and Transmission-Based Precautions

o Cloze (Drop-Down): Identifying Signs of Infection

o Matrix/Grid: Infection Control Measures and Patient Care

16. Summary of the Chapters

o Comprehensive Answer Key for All Questions

o Detailed Rationales for Correct and Incorrect Answers

o References to Evidence-Based Nursing Guidelines and Textbooks

Overview:

This eBook is designed to help nursing students prepare for the NGN-style NCLEX by providing

a variety of practice questions that cover fundamental nursing concepts. The comprehensive

table of contents ensures that students can focus on specific areas where they need more practice,

while the detailed answer key and rationales offer insight into the correct application of clinical

judgment and critical thinking in nursing practice.

Chapter 1: Nursing Assessment and Patient Safety

Case Study: Diabetic Ketoacidosis (DKA) Management

Scenario: A client with a history of diabetes mellitus presents with blurred vision, thirst, and

frequent urination.

 Question: "What is the nurse's priority intervention?"

o Options:

 Administer prescribed insulin. (Correct Answer)

 Restrict fluid intake.

 Encourage the client to rest.

 Apply a cool compress to the forehead.

Rationale: The symptoms described (blurred vision, thirst, and frequent urination) are indicative

of hyperglycemia, which can lead to diabetic ketoacidosis (DKA) if not promptly treated.

Administering insulin is the priority intervention because it helps lower the blood glucose level,

preventing further complications such as DKA. Restricting fluid intake is incorrect because

clients with hyperglycemia often require fluids to prevent dehydration. Encouraging rest and

applying a cool compress may provide comfort but do not address the underlying hyperglycemia.

Extended Multiple Response: Warfarin Safety Precautions

Scenario: A nurse is providing discharge instructions to a client who has been prescribed

warfarin.

 Question: "Which instructions should the nurse include to ensure the client's safety?

Select all that apply."

o Options:

 Avoid leafy green vegetables.

 Use an electric razor for shaving. (Correct Answer)

 Monitor for signs of bleeding. (Correct Answer)

 Take aspirin for headache relief.

 Keep scheduled blood test appointments. (Correct Answer)

Rationale:

 Use an electric razor for shaving : Warfarin is an anticoagulant, which increases the risk

of bleeding. Using an electric razor instead of a traditional one reduces the risk of cuts

and bleeding.

 Monitor for signs of bleeding : Clients on warfarin are at risk for bleeding. They should

be educated to monitor for signs such as bruising, nosebleeds, and blood in the urine or

stool.

 Keep scheduled blood test appointments : Regular blood tests (INR/PT) are necessary

to monitor the therapeutic level of warfarin and adjust the dosage as needed to reduce the

risk of either bleeding or clotting.

 Avoid leafy green vegetables : This is incorrect. Clients should not avoid leafy greens

altogether but should maintain a consistent intake because these foods are high in vitamin

K, which can affect warfarin's effectiveness.

 Take aspirin for headache relief : This is incorrect. Aspirin is also an anticoagulant and

can increase the risk of bleeding when taken with warfarin. Clients should use alternative

pain relief options and consult their healthcare provider.

Highlight Text: Fall Prevention Strategies

Scenario: A nurse is preparing a care plan for a client with a risk of falls.

 Question: "Which interventions should the nurse include to prevent falls? Select all that

apply."

o Options:

 Ensure adequate lighting in the client's room. (Correct Answer)

 Place the call light within the client's reach. (Correct Answer)

 Keep the bed in the highest position.

 Remove all assistive devices from the room.

 Apply non-slip socks to the client's feet. (Correct Answer)

Rationale:

 Ensure adequate lighting in the client's room : Proper lighting reduces the risk of falls

by improving visibility, especially for clients who may have visual impairments.

 Place the call light within the client's reach : This ensures that the client can easily call

for assistance if needed, reducing the likelihood of attempting to get up unassisted and

falling.

 Apply non-slip socks to the client's feet : Non-slip socks provide traction on slippery

surfaces, decreasing the risk of slipping and falling.

 Keep the bed in the highest position : Incorrect. Keeping the bed in a low position

minimizes the risk of injury if the client does fall out of bed.

 Remove all assistive devices from the room : Incorrect. Assistive devices (e.g., walkers,

canes) are crucial for clients who need support with mobility. Removing these could

increase the risk of falls.

Cloze (Drop-Down): Identifying Postoperative Complications

Scenario: A nurse is assessing a client who has been taking opioid analgesics for postoperative

pain.

 Question: "The nurse should monitor the client for (select) ________ as a common side

effect of opioid use."

o Options:

 Constipation (Correct Answer)

 Hypotension

 Hyperactivity

Rationale: Opioid analgesics commonly cause constipation by slowing down gastrointestinal

motility. Clients on opioids should be monitored for this side effect, and preventive measures,

such as increasing fluid and fiber intake and possibly using stool softeners, should be considered.

While opioids can cause hypotension in some cases, it is not as common or as directly related to

their use as constipation. Hyperactivity is not a known side effect of opioids; they are more likely

to cause sedation rather than hyperactivity.

Matrix/Grid: Isolation Precautions and Client Conditions

Scenario: A nurse is caring for clients with various types of isolation precautions.

 Question: "Match the type of precaution with the appropriate client condition."

o Matrix:

 Precautions:

 Contact precautions - MRSA infection (Correct Answer)

 Droplet precautions - Influenza (Correct Answer)

 Airborne precautions - Tuberculosis (Correct Answer)

Rationale:

 Contact precautions - MRSA infection : MRSA (Methicillin-resistant Staphylococcus

aureus) is spread through direct contact with contaminated surfaces or skin. Contact

precautions, including wearing gloves and gowns, help prevent the spread.

 Droplet precautions - Influenza : Influenza is spread through respiratory droplets when

an infected person coughs or sneezes. Droplet precautions involve wearing masks and

maintaining a safe distance to prevent transmission.

 Airborne precautions - Tuberculosis : Tuberculosis (TB) is an airborne disease spread

through tiny particles that can remain suspended in the air for extended periods. Airborne

precautions include using N95 respirators and placing the client in a negative-pressure

room to prevent the spread of infection.

Chapter 2: Fluid and Electrolyte Balance

Case Study: Dehydration and Rehydration Therapy

Scenario: A client is admitted with a diagnosis of dehydration due to severe vomiting and

diarrhea.

 Question: "What is the nurse's priority intervention?"

o Options:

 Administer IV fluids as prescribed. (Correct Answer)

 Offer the client sips of water.

 Encourage the client to eat small, frequent meals.

 Apply a warm compress to the abdomen.

Rationale: Severe vomiting and diarrhea can lead to significant fluid loss, resulting in

dehydration. The priority intervention for severe dehydration is to administer IV fluids as

prescribed to quickly replace lost fluids and restore electrolyte balance. Oral rehydration

(offering sips of water) is helpful for mild dehydration, but not the priority in severe cases where

IV fluids are necessary. Encouraging food intake is not appropriate until the client is rehydrated

and stable. Applying a warm compress to the abdomen does not address dehydration.

Extended Multiple Response: Managing Fluid Volume Excess

Scenario: A nurse is caring for a client with chronic kidney disease (CKD) who reports

shortness of breath and swelling in the lower extremities.

 Question: "Which interventions should the nurse implement to manage fluid volume

excess? Select all that apply."

o Options:

 Administer the prescribed diuretic. (Correct Answer)

 Restrict sodium intake.

 Elevate the client's legs on pillows. (Correct Answer)

 Encourage the client to increase fluid intake.

 Measure the client’s abdominal girth daily.

Rationale:

 Administer the prescribed diuretic: Diuretics help the body remove excess fluid, which

is essential for managing fluid volume excess, especially in clients with conditions like

CKD.

 Restrict sodium intake: Sodium can cause the body to retain fluid, so restricting it helps

reduce fluid overload.

 Elevate the client's legs on pillows: This intervention helps reduce edema by promoting

venous return and reducing the pooling of fluid in the lower extremities.

 Encourage the client to increase fluid intake: Incorrect. Increasing fluid intake can

worsen fluid volume excess, especially in clients with impaired kidney function.

 Measure the client’s abdominal girth daily: While this can monitor fluid status, it is

not an intervention to manage fluid volume excess directly.

Highlight Text: Identifying Signs of Hypokalemia

Scenario: A nurse is reviewing the lab results of a client who has been experiencing muscle

weakness and fatigue.

 Question: "Highlight the laboratory findings that indicate hypokalemia."

o Text:

 Serum potassium: 2.8 mEq/L

 Serum calcium: 9.2 mg/dL

 Serum sodium: 140 mEq/L

 Hemoglobin: 13.5 g/dL

o Correct Answer: Serum potassium: 2.8 mEq/L

Rationale: The normal range for serum potassium is typically 3.5-5.0 mEq/L. A potassium level

of 2.8 mEq/L indicates hypokalemia , which can cause muscle weakness, fatigue, and

arrhythmias. The other laboratory values listed (serum calcium, serum sodium, and hemoglobin)

are within normal ranges and do not indicate hypokalemia. Hypokalemia must be addressed

promptly as it can have significant cardiovascular implications.

Cloze (Drop-Down): Assessing Fluid Volume Status

Scenario: A nurse is assessing a client with fluid volume excess.

 Question: "The nurse should expect to find (select) ________ as a clinical manifestation

of fluid volume excess."

o Options:

 Edema (Correct Answer)

 Dry mucous membranes

 Hypotension

Rationale: Edema is a common clinical manifestation of fluid volume excess, resulting from

excess fluid accumulating in the interstitial spaces. Fluid volume excess can also lead to

symptoms like weight gain, hypertension, and dyspnea. Dry mucous membranes are typically

associated with dehydration (fluid volume deficit), and hypotension is more commonly seen in

fluid volume deficit rather than excess.

Matrix/Grid: Electrolyte Imbalances and Nursing Interventions

Scenario: A nurse is planning care for clients at risk for electrolyte imbalances.

 Question: "Match each nursing intervention with the type of electrolyte imbalance it

aims to prevent."

o Matrix:

 Nursing Interventions:

 Administer IV potassium chloride as prescribed. - Hypokalemia

(Correct Answer)

 Monitor daily weights. - Fluid volume excess (Correct Answer)

 Restrict fluid intake. - Fluid volume excess (Correct Answer)

Rationale:

 Administer IV potassium chloride as prescribed - Hypokalemia : Administering

potassium chloride helps prevent or correct hypokalemia by replenishing potassium

levels in the body.

 Monitor daily weights - Fluid volume excess : Daily weight monitoring is an essential

intervention for detecting fluid retention, which is crucial in managing fluid volume

excess.

 Restrict fluid intake - Fluid volume excess : Fluid restriction is necessary for clients

with fluid volume excess to prevent further accumulation of fluids, especially in

conditions like heart failure and kidney disease.

Chapter 3: Cardiovascular Nursing Care

Case Study: Hypertensive Crisis Management

Scenario: A client with a history of hypertension is admitted with a blood pressure of 200/

mmHg.

 Question: "What is the nurse's immediate priority?"

o Options:

 Administer antihypertensive medication as prescribed. (Correct

Answer)

 Place the client in a supine position.

 Apply ice packs to the client's forehead.

 Encourage the client to take slow, deep breaths.

Rationale: The client is experiencing a hypertensive crisis , which requires immediate

intervention to lower blood pressure and reduce the risk of life-threatening complications like

stroke or myocardial infarction. Administering antihypertensive medication as prescribed is

the priority intervention to quickly lower the client's blood pressure. Placing the client in a

supine position, applying ice packs, or encouraging slow breathing do not address the urgent

need to lower the dangerously high blood pressure.

Extended Multiple Response: Nursing Interventions for Heart Failure

Scenario: A nurse is caring for a client with chronic heart failure who reports shortness of breath

and swelling in the lower extremities.

 Question: "Which interventions should the nurse include in the care plan? Select all that

apply."

o Options:

 Administer prescribed diuretics. (Correct Answer)

 Monitor daily weights. (Correct Answer)

 Elevate the legs while the client is sitting. (Correct Answer)

 Encourage a high-sodium diet.

 Restrict physical activity completely.

Rationale:

 Administer prescribed diuretics: Diuretics help remove excess fluid from the body,

reducing symptoms like edema and improving respiratory status in heart failure clients.

 Monitor daily weights: Daily weight monitoring is crucial to detect fluid retention early,

which can indicate worsening heart failure.

 Elevate the legs while the client is sitting: Elevating the legs helps reduce dependent

edema and promotes venous return.

 Encourage a high-sodium diet: Incorrect. High sodium intake can lead to fluid retention

and exacerbate heart failure.

 Restrict physical activity completely: Incorrect. While excessive physical activity

should be avoided, some level of activity is essential to maintain overall cardiovascular

health. Clients with heart failure should be encouraged to engage in low-intensity

activities as tolerated.

Highlight Text: Medication Adherence in Hypertension

Scenario: A nurse is providing discharge instructions to a client with hypertension about

medication adherence.

 Question: "Highlight the statements the nurse should emphasize regarding medication

adherence."

o Text:

 Take medications only when symptoms are present.

 Skipping doses can increase the risk of complications. (Correct

Answer)

 Take medications at the same time every day. (Correct Answer)

 If you feel better, you can stop taking your medication.

Rationale: Medication adherence is crucial for managing hypertension effectively. Clients

should understand that skipping doses can increase the risk of complications like stroke and

heart attack, even if they are asymptomatic. Taking medications at the same time every day

helps maintain consistent blood levels and control blood pressure. The other options are

incorrect: Taking medication only when symptoms are present or stopping medication when

feeling better can lead to uncontrolled blood pressure and increased risk of serious

cardiovascular events.

Cloze (Drop-Down): Reducing Cardiac Workload Post-MI

Scenario: A nurse is caring for a client post-myocardial infarction (MI).

 Question: "The nurse should (select) ________ to reduce cardiac workload and promote

recovery."

o Options:

 Encourage periods of rest (Correct Answer)

 Increase fluid intake

 Promote early ambulation

Rationale: Following an MI, it is essential to reduce cardiac workload to prevent further

cardiac damage and promote healing. Encouraging periods of rest helps decrease the heart's

demand for oxygen, allowing it to recover. Increasing fluid intake can lead to fluid overload and

strain the heart, while promoting early ambulation too aggressively can increase the heart's

workload prematurely.

Matrix/Grid: Cardiovascular Conditions and Nursing Interventions

Scenario: A nurse is providing care to clients with different cardiovascular conditions.

 Question: "Match each intervention with the appropriate client condition."

o Matrix:

 Interventions:

 Administer nitroglycerin as prescribed. - Myocardial infarction

(Correct Answer)

 Monitor for signs of bleeding. - Atrial fibrillation on

anticoagulants (Correct Answer)

 Encourage a low-sodium diet. - Heart failure (Correct Answer)

Rationale:

 Administer nitroglycerin as prescribed - Myocardial infarction: Nitroglycerin helps

alleviate chest pain (angina) by dilating coronary arteries, improving blood flow to the

heart muscle, and reducing myocardial oxygen demand.

 Monitor for signs of bleeding - Atrial fibrillation on anticoagulants: Clients with

atrial fibrillation are often prescribed anticoagulants to prevent thromboembolic events.

Monitoring for signs of bleeding is crucial due to the increased risk of bleeding

associated with anticoagulant therapy.

 Encourage a low-sodium diet - Heart failure: A low-sodium diet helps reduce fluid

retention and decreases the workload on the heart, which is essential in managing heart

failure. Sodium restriction helps prevent exacerbation of heart failure symptoms.

Chapter 4: Respiratory Management

Case Study: COPD Exacerbation and Oxygen Therapy

Scenario: A client with chronic obstructive pulmonary disease (COPD) is experiencing

increased shortness of breath and is admitted to the hospital for an exacerbation. The client is

receiving 2 L/min of oxygen via nasal cannula.

 Question: "What is the nurse's priority intervention?"

o Options:

 Administer prescribed bronchodilator. (Correct Answer)

 Place the client in a supine position.

 Encourage oral fluid intake.

 Provide a high-carbohydrate diet.

Rationale: Clients with COPD exacerbation experience airway constriction and airflow

limitation, leading to increased shortness of breath. Administering a prescribed

bronchodilator is the priority as it helps to relax the airway muscles, reduce bronchospasm, and

improve airflow. Placing the client in a supine position can worsen breathing. Encouraging fluids

and providing a high-carbohydrate diet may be part of the overall care but are not the priority

interventions for acute exacerbation.

Extended Multiple Response: Care Plan for Clients with Pneumonia

Scenario: A nurse is caring for a client diagnosed with pneumonia who is experiencing

productive cough and fever.

 Question: "Which interventions should the nurse include in the care plan? Select all that

apply."

o Options:

 Administer antibiotics as prescribed. (Correct Answer)

 Encourage the client to use an incentive spirometer. (Correct Answer)

 Promote fluid intake of at least 2,500 mL per day. (Correct Answer)

 Restrict the client to bed rest.

 Administer cough suppressants to stop coughing.

Rationale:

 Administer antibiotics as prescribed: Pneumonia is often caused by a bacterial

infection, so antibiotics are essential to treat the infection.

 Encourage the client to use an incentive spirometer: Using an incentive spirometer

helps improve lung expansion and prevent atelectasis.

 Promote fluid intake of at least 2,500 mL per day: Increased fluid intake helps thin

respiratory secretions, making it easier for the client to expectorate mucus.

 Restrict the client to bed rest: Incorrect. While rest is important, mobilization is

encouraged to prevent complications such as deep vein thrombosis (DVT) and to improve

respiratory function.

 Administer cough suppressants to stop coughing: Incorrect. In pneumonia, coughing is

beneficial as it helps clear the airways of mucus and infectious material. Suppressing the

cough can lead to retention of secretions.

Highlight Text: Proper Use of Metered-Dose Inhalers (MDIs)

Scenario: A nurse is teaching a client with asthma how to use a metered-dose inhaler (MDI).

 Question: "Highlight the instructions the nurse should include for proper MDI use."

o Text:

 Shake the inhaler well before each use. (Correct Answer)

 Exhale fully before placing the inhaler in your mouth. (Correct

Answer)

 Inhale quickly and deeply as you press down on the inhaler.

 Hold your breath for 5 to 10 seconds after inhalation. (Correct

Answer)

Rationale: Proper MDI use involves several key steps:

 Shake the inhaler well before each use: This ensures the medication is properly mixed

for effective delivery.

 Exhale fully before placing the inhaler in your mouth: This helps to maximize the

inhaled dose of medication by emptying the lungs before taking the dose.

 Hold your breath for 5 to 10 seconds after inhalation: This allows the medication to

settle in the lungs and provides optimal therapeutic effect.

 Inhale quickly and deeply as you press down on the inhaler is incorrect; instead, the

client should inhale slowly and deeply to ensure the medication reaches the lower

airways.

Cloze (Drop-Down): Identifying Respiratory Therapy Complications

Scenario: A nurse is monitoring a client who is receiving a blood transfusion.

 Question: "The nurse should monitor the client for (select) ________ as a possible

transfusion reaction."

o Options:

 Fever (Correct Answer)

 Hypertension

 Hypoglycemia

Rationale: Fever is a common sign of a transfusion reaction, indicating that the body is reacting

to the transfused blood. This can occur due to several reasons, such as an immune response to

white blood cells or proteins in the donor blood. Hypertension is not typically associated with

transfusion reactions; in fact, reactions can sometimes cause hypotension. Hypoglycemia is not

related to blood transfusions.

Matrix/Grid: Respiratory Therapies and Nursing Interventions

Scenario: A nurse is caring for clients receiving various respiratory therapies.

 Question: "Match each respiratory therapy with the appropriate nursing intervention."

o Matrix:

 Therapies:

 Incentive spirometry - Instruct the client to take slow, deep

breaths. (Correct Answer)

 Chest physiotherapy - Perform percussion on the chest. (Correct

Answer)

 Oxygen therapy - Monitor the client's oxygen saturation levels.

(Correct Answer)

Rationale:

 Incentive spirometry - Instruct the client to take slow, deep breaths: Incentive

spirometry encourages the client to take slow, deep breaths to increase lung volume and

prevent atelectasis.

 Chest physiotherapy - Perform percussion on the chest: Chest physiotherapy involves

percussion to help loosen mucus in the airways, making it easier to cough up.

 Oxygen therapy - Monitor the client's oxygen saturation levels: Oxygen therapy

requires careful monitoring of oxygen saturation to ensure the client is receiving the

appropriate amount of oxygen without causing hyperoxia, especially in clients with

conditions like COPD.

Chapter 5: Gastrointestinal and Nutritional Nursing

Case Study: Acute Pancreatitis Management

Scenario: A client is admitted with acute pancreatitis and reports severe abdominal pain

radiating to the back.

 Question: "What is the nurse's priority intervention?"

o Options:

 Administer prescribed pain medication. (Correct Answer)

 Provide oral fluids to the client.

 Encourage ambulation.

 Place the client in a supine position.

Rationale: In acute pancreatitis, severe abdominal pain is a hallmark symptom and can be

extremely distressing. The priority intervention is to administer prescribed pain medication to

manage the client’s pain and reduce discomfort. Providing oral fluids is contraindicated in the

acute phase to avoid stimulating the pancreas. Ambulation is not appropriate until the client's

pain is under control and they are stabilized. Placing the client in a supine position may

exacerbate the pain; a more comfortable position, such as sitting up and leaning forward, is often

preferred.

Extended Multiple Response: Dietary Modifications for Gout

Scenario: A nurse is educating a client diagnosed with gout about dietary modifications to

prevent exacerbations.

 Question: "Which dietary instructions should the nurse include in the teaching? Select all

that apply."

o Options:

 Increase intake of dairy products.

 Limit intake of red meats and shellfish. (Correct Answer)

 Avoid alcohol consumption. (Correct Answer)

 Drink 2 to 3 liters of water daily. (Correct Answer)

 Increase consumption of purine-rich foods.

Rationale:

 Limit intake of red meats and shellfish: Red meats and shellfish are high in purines,

which can increase uric acid levels and precipitate gout attacks.

 Avoid alcohol consumption: Alcohol can interfere with the elimination of uric acid,

contributing to hyperuricemia and gout flare-ups.

 Drink 2 to 3 liters of water daily: Adequate hydration helps dilute urine and promotes

the excretion of uric acid, reducing the risk of crystal formation in the joints.

 Increase intake of dairy products: Although dairy products are low in purines and can

be part of a gout-friendly diet, they are not directly indicated in this scenario.

 Increase consumption of purine-rich foods: Incorrect. Foods high in purines should be

avoided as they can lead to an increase in uric acid levels.

Highlight Text: GERD Lifestyle Modifications

Scenario: A nurse is educating a client with gastroesophageal reflux disease (GERD) on lifestyle

changes to manage symptoms.

 Question: "Highlight the lifestyle modifications that the client should implement."

o Text:

 Avoid lying down immediately after meals. (Correct Answer)

 Wear tight-fitting clothes to support the abdomen.

 Eat small, frequent meals. (Correct Answer)

 Drink carbonated beverages to aid digestion.

Rationale:

 Avoid lying down immediately after meals: This helps prevent reflux by using gravity

to keep stomach contents from flowing back into the esophagus.

 Eat small, frequent meals: Smaller meals reduce the risk of overfilling the stomach,

which can trigger reflux symptoms.

 Wear tight-fitting clothes to support the abdomen: Incorrect. Tight-fitting clothes can

increase abdominal pressure and exacerbate GERD symptoms.

 Drink carbonated beverages to aid digestion: Incorrect. Carbonated beverages can

increase bloating and worsen GERD symptoms.

Cloze (Drop-Down): Iron Supplementation in Anemia

Scenario: A client with anemia is prescribed oral iron supplements.

 Question: "The nurse should instruct the client to (select) ________ to enhance the

absorption of iron."

o Options:

 Take the supplement with orange juice (Correct Answer)

 Take the supplement with milk

 Take the supplement on an empty stomach

Rationale: Iron is better absorbed in an acidic environment, and taking the supplement with

orange juice (which is high in vitamin C) enhances its absorption. Taking iron with milk is not

recommended because calcium in milk can inhibit iron absorption. While taking iron on an

empty stomach may improve absorption, it can also cause gastrointestinal upset in some clients.

The best strategy is to take iron with a vitamin C source like orange juice.

Nursing Study Resources Download Links

 Pediatric Nursing 2023/2024/2025 https://docmerit.com/bundle/show/rn-ati-pediatric-assessment-exam- 2023 - ngn-latest-versions-rn- atipediatric-nursing-exam- 70 - ngn-questions-with-answers https://docmerit.com/bundle/show/rn-ati- pediatric-nursing-proctored-exam-with-ngn- 2023 - 2024  Maternal NewBorn Nursing 2023/2024/2025 https://docmerit.com/bundle/show/ati-rn- maternal-exam- 2021 - 2024 - 9 - versions-with-answers https://docmerit.com/bundle/show/ati-rn- maternal-ob-proctored-exam- 2023 - with-ngn- 10 - versions https://docmerit.com/bundle/show/ati-rn-maternal-proctored-assessment- 2023 - 2024 - 20 - versions-rnati- maternal-newborn-proctored-exam- 20 - versions  Pharmacology 2023/2024/2025 https://docmerit.com/bundle/show/ati-rn-proctored-exams- 2024 - with-ngn-bundle-pediatric- mentalhealth-maternal-pharmacology https://docmerit.com/bundle/show/ati-rn-pharmacology- 2022 - 2024 - 6 - versions-with-answers https://docmerit.com/doc/show/rn-ati-pharmacology-question-bank-200-questions-and-answers  Medical Surgical 2023/2024/2025 https://docmerit.com/doc/show/medical-surgical-nursing-ngn-style-questions-and-answers https://docmerit.com/bundle/show/rn-ati-proctored-pharmacology-nutrition-pediatric-mental-health- fundamentals-maternal-leadership-medsurg-adult-medsurg-community-health-2023-2024-exam-2

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Nursing Study Resources Download Links

 Leadership 2023/2024/2025 https://docmerit.com/bundle/show/ati-rn-leadership-proctored- assessment- 70 - questions- 2 - versions https://docmerit.com/bundle/show/ati-rn-leadership- 2021 - 2024 - 5 - versions-with-answers https://docmerit.com/bundle/show/rn-ati-proctored-pharmacology-nutrition-pediatric-mental- healthfundamentals-maternal-leadership-medsurg-adult-medsurg-community-health- 2023 - 2024 - exam  Comprehensive Predictor 2023/2024/2025 6 versions and Retakes https://docmerit.com/bundle/show/rn-ati-comprehensive-assessment-exam- 2023 - 2024 https://docmerit.com/bundle/show/rn-comprehensive-predictor- 2023 - 2024 - exam-1st-2nd-3rdattempts- and-retakes

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