Questions 151

NCLEX-RN

NCLEX-RN Test Bank

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Question 1 of 5

A client with atrial fibrillation is prescribed digoxin (Lanoxin). Which finding indicates a potential toxicity?

Correct Answer: B

Rationale: Visual disturbances, such as blurred or yellow vision, are classic signs of digoxin toxicity, requiring immediate reporting.

Question 2 of 5

Which of the following discharge instructions about thermal injury should be given to a client with peripheral vascular disease? Select all that apply.

Correct Answer: B,C,E,G

Rationale: Clients with peripheral vascular disease should wear warm clothing, check bath water temperature, avoid crossing legs to maintain circulation, and use sunscreen to protect skin. Electric heating pads, hot water bottles, and heating blankets risk burns due to impaired sensation.

Question 3 of 5

Which of the following techniques is correct when administering a subcutaneous injection?

Correct Answer: B

Rationale: A subcutaneous injection is correctly administered at a 45-degree angle (or 90 degrees for obese patients) using a 5/8-inch needle, pinching the skin, without an air bubble.

Question 4 of 5

A client with a history of rheumatoid arthritis is prescribed etanercept (Enbrel). The nurse should monitor the client for which of the following adverse effects?

Correct Answer: A

Rationale: Etanercept, a biologic, increases infection risk due to immunosuppression.

Question 5 of 5

The registered nurse is observing a new nurse auscultate the breath sounds of a client. Which action by the new nurse should lead the registered nurse to determine that further teaching is needed?

Correct Answer: A

Rationale: The bell of the stethoscope is not used to auscultate breath sounds. The client ideally should sit up and breathe slowly and deeply through the mouth. The diaphragm of the stethoscope, which is warmed before use, is placed directly on the client's skin, not over a gown or clothing.

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