Questions 151

NCLEX-RN

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Question 1 of 5

A client with a history of type 1 diabetes is admitted with diabetic ketoacidosis. The nurse should prioritize which of the following interventions?

Correct Answer: A

Rationale: Intravenous regular insulin is the priority to lower blood glucose and halt ketogenesis in diabetic ketoacidosis.

Question 2 of 5

Mebendazole (Vermox) is prescribed for an 8-year-old child with pinworms. The child has an 18-month-old brother and a 4-year-old sister. The nurse should be sure that the parents are also treating which of the following family members with this drug?

Correct Answer: C

Rationale: Pinworms are highly contagious, so all household members should be treated with mebendazole to prevent reinfection, regardless of symptoms.

Question 3 of 5

The nurse is preparing to administer a dose of warfarin (Coumadin) to a client. The client's International Normalized Ratio (INR) is 4.0. What should the nurse do?

Correct Answer: B

Rationale: An INR of 4.0 is above the therapeutic range (2-3), indicating a risk of bleeding, so the nurse should hold the dose and notify the physician.

Question 4 of 5

When a rubella vaccine is administered to a client who delivered a healthy newborn 2 days ago, the nurse provides instructions to the client regarding the potential risks associated with this vaccination. Which statement by the client indicates an understanding of the medication?

Correct Answer: D

Rationale: Rubella vaccine is a live attenuated virus that evokes an antibody response and provides immunity for approximately 15 years. Because rubella is a live vaccine, it will act as the virus and is potentially teratogenic in the organogenesis phase of fetal development. The client needs to be informed about the potential effects this vaccine may have and the need to avoid becoming pregnant for a period of 2 to 3 months afterward. Sunlight has no effect on the person who is vaccinated. The vaccine may cause local or systemic reactions, but all are mild and short-lived. Abstinence from sexual intercourse is not necessary, unless another form of effective contraception is not being used.

Question 5 of 5

A client with a history of peptic ulcer disease is admitted with hematemesis. The nurse should prioritize which of the following interventions?

Correct Answer: A

Rationale: Intravenous pantoprazole reduces acid production and stabilizes bleeding in peptic ulcer disease.

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