Questions 151

NCLEX-RN

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Question 1 of 5

A hospice nurse is caring for a client with breast cancer and brain metastasis. The nurse is reviewing the lab report below. According to the information in the chart, what should the nurse do next?

Correct Answer: C

Rationale: The normal calcium level is 9.0 to 10.5 mg/dL. Hypercalcemia is commonly seen with malignant disease and metastases. The other laboratory values are normal. Hypercalcemia can be treated with fluids, furosemide (Lasix), or administration of calcitonin. Failure to treat hypercalcemia can cause muscle weakness, changes in level of consciousness, nausea, vomiting, abdominal pain, and dehydration. Although the client is on hospice care, she will still need palliative treatment. Comfort and risk reduction are components of hospice care.

Question 2 of 5

A client who has glaucoma has been prescribed timolol (Timoptic) eyedrops. Which of the following instructions should the nurse give the client about the administration of the eyedrops?

Correct Answer: B

Rationale: Timolol eyedrops may cause transient eye discomfort, such as stinging or burning, which is a common side effect. Instilling drops only when eyes are irritated is incorrect, as timolol requires regular dosing. Refrigeration is not necessary, and reevaluation timing depends on the physician's plan, not a fixed month.

Question 3 of 5

The nurse is assessing a client with suspected appendicitis. Which of the following findings would support this diagnosis?

Correct Answer: A, B

Rationale: Pain at McBurney's point and decreased bowel sounds are classic signs of appendicitis due to peritoneal irritation and intestinal obstruction.

Question 4 of 5

An adult client is admitted to the emergency department after a burn injury. The burn initially affected the upper half of the client's anterior torso, and there were circumferential burns to the lower half of both of the arms. The client's clothes caught on fire, and the client ran causing subsequent burn injuries to the entire face (anterior half of the head), and the upper half of the posterior torso. Using the rule of nines, the extent of the burn injury would be what percent?

Correct Answer: 31.50%

Rationale: According to the rule of nines, with the initial burn, the upper half of the anterior torso equals 9% and the lower half of both arms equals 9%. The subsequent burn included the anterior half of the head equaling 4.5% and the upper half of posterior torso equaling 9%. This totals 31.5%.

Question 5 of 5

Which of the following actions by the nurse will most likely ensure that the correct client receives a medication? Select all that apply.

Correct Answer: A,B,E

Rationale: Using two identifiers, such as the client's name, armband, and date of birth, ensures accurate medication administration. Room number and visual recognition are not reliable.

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