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Questions 164

NCLEX-PN

NCLEX-PN Test Bank

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Extract:


Question 1 of 5

A client with hyperkalemia is to receive an infusion of $250 \mathrm{~mL}$ of $20% glucose with 20 units of regular insulin. The rationale for this therapy is:

Correct Answer: C

Rationale: Insulin facilitates glucose uptake by cells, which drives potassium into cells, lowering serum potassium levels in hyperkalemia.

Question 2 of 5

The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action?

Correct Answer: A

Rationale: Normal ICP is less than 15. 66 is a high reading, and the RN and the physician should be notified. Answer B would be the action if the reading was normal, so it is incorrect. Answers C and D would not be appropriate actions, so they are wrong.

Extract:

Laboratory reference ranges
Hematocrit
39%-59%
(0.39-0.59)


Question 3 of 5

The nurse is collecting data from a 2-week-old client who has tetralogy of Fallot. Which of the following findings would be a priority to follow up?

Correct Answer: C

Rationale: Elevated hematocrit indicates polycythemia, a serious complication of tetralogy of Fallot. Knee-chest relief , weight gain , and murmurs are expected.

Extract:


Question 4 of 5

The nurse is caring for a client who has a prescription for furosemide 1 mg/kg PO every 8 hours. The client weighs 44 lb (20 kg). The nurse has furosemide oral solution 10 mg/mL available. How many mL should the nurse administer to the client with each dose? Record your answer using a whole number.

Correct Answer: B

Rationale: Dose: 1 mg/kg × 20 kg = 20 mg. Solution: 20 mg ÷ 10 mg/mL = 2 mL .

Question 5 of 5

The school nurse suspects that a third grade child might have attention deficit hyperactivity disorder (ADHD). Prior to referring the child for further evaluation, the nurse should

Correct Answer: C

Rationale: Compile a history of behavior patterns and developmental accomplishments. A comprehensive history is essential for accurate ADHD diagnosis.

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