NCLEX Questions, NCLEX Practice Test RN Questions, NCLEX-RN Questions, Nurselytic

Questions 158

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Question 1 of 5

A client admitted with a diagnosis of possible myocardial infarction is admitted to the unit from the emergency room. The nurse's first action when admitting the client will be to:

Correct Answer: B

Rationale: Obtaining vital signs is important after connecting the client to the monitor because vital signs should be stable before the client is discharged from the emergency room. All are important, but the first priority is to monitor the client's rhythm. If the client is in severe pain, pain medication should be given after connecting him to the monitor and obtaining vital signs. Completion of the history profile is the least important of the nursing actions.

Question 2 of 5

The nurse is caring for a client who is receiving terbutaline for preterm labor. Which side effect should the nurse monitor for?

Correct Answer: C

Rationale: Terbutaline a beta-agonist tocolytic commonly causes maternal tachycardia due to its stimulatory effects on the cardiovascular system. Maternal bradycardia fetal hypoglycemia and macrosomia are not associated side effects.

Question 3 of 5

The nurse is teaching a client with a history of osteoporosis about fall prevention. The nurse should tell the client to:

Correct Answer: A

Rationale: Removing clutter prevents falls in osteoporosis, reducing fracture risk.

Question 4 of 5

A child is admitted with suspected epiglottitis. Which action is not a part of the nursing care?

Correct Answer: B

Rationale: Assessing the throat with a tongue blade is contraindicated in suspected epiglottitis as it may trigger airway obstruction. Vital signs oxygen and antibiotics are appropriate interventions.

Question 5 of 5

When a client is receiving vasoactive therapy IV, such as dopamine (Intropin), and extravasation occurs, the nurse should be prepared to administer which of the following medications directly into the site?

Correct Answer: A

Rationale: Phentolamine is given to counteract the-adrenergic effects that cause ischemia and necrosis of local tissue. Epinephrine is an endogenous catecholamine that produces vasoconstriction and increases heart rate and contractility. Phenylephrine causes constriction of arterioles of skin, mucous membranes, and viscera, which in turn can cause ischemia and necrosis. Sodium bicarbonate is an alkalinizing agent that is incompatible with dopamine.

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