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Questions 164

NCLEX-PN

NCLEX-PN Test Bank

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Extract:


Question 1 of 5

An adult client is to have a portable chest x-ray in his room. The client's wife and pregnant daughter are visiting. Which action is essential for the nurse?

Correct Answer: D

Rationale: Removing visitors, especially a pregnant woman, minimizes radiation exposure, the essential safety action during a chest x-ray.

Extract:

Exhibit 1
Vital signs

0800
Temperature 98.4 F (36.8 C)
Blood pressure 110/72 mm Hg
Heart rate 52/min
Respirations 16/min

Exhibit 2
Laboratory results

0800
Hematocrit
Male: 42%–52%
(0.42-0.52)
Female: 37%–47%
(0.37–0.47) 40%
(0.4)
Hemoglobin
Male: 14.0–18.0 g/dL
(140–180 g/L)
Female: 12.0–16.0 g/dL
(120–160 g/L) 14.0 g/dL
(140 g/L)
Platelets
150,000–400,000/mm3
(150–400 × 109/L) 200,000/mm3
(200 × 109/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L) 4.0 mEq/L
(4.0 mmol/L)


Exhibit 3
Medication administration record

Allergies: No known drug allergies

Medications Time
Aspirin: 81 mg by mouth, daily 0900
Docusate sodium: 100 mg by mouth, daily 0900
Lisinopril: 5 mg by mouth, daily 0900
Metoprolol: 100 mg by mouth, twice daily 0900, 1700
Simvastatin: 20 mg by mouth, daily 2000


Question 2 of 5

A client with ST segment elevation myocardial infarction is due for 0900 medications. Based on the data shown in the exhibit, which medications should the nurse administer? Select all that apply.

Correct Answer: A,C,D,E

Rationale: Aspirin (antiplatelet), lisinopril (ACE inhibitor), metoprolol (beta-blocker), and simvastatin (statin) are standard for STEMI to reduce clot formation, blood pressure, and cholesterol. Docusate is unrelated to STEMI management.

Extract:


Question 3 of 5

The home health nurse is caring for an 85-year-old client. It would require immediate follow-up if the client is reporting

Correct Answer: A

Rationale: A painful red area on the buttocks suggests a pressure injury, requiring immediate intervention to prevent worsening. Edema, vision loss, and memory issues are concerning but less urgent.

Question 4 of 5

The nurse is giving home care to an elderly client with angina pectoris and Type 2 diabetes mellitus. Which observation is of most concern and should be reported immediately?

Correct Answer: A

Rationale: Chest discomfort in a client with angina suggests possible cardiac ischemia, requiring immediate reporting to prevent myocardial infarction. Brown spots, toenail pain, or exertional dyspnea are less urgent.

Question 5 of 5

The nurse is talking with the parent of a 1-day-old newborn who had a circumcision using the plastic ring method. Which of the following statements by the parent would require follow-up?

Correct Answer: D

Rationale: Yellow exudate is normal during circumcision healing, not a sign of infection, requiring further teaching. Contacting the provider for persistent bleeding, avoiding alcohol wipes, and leaving the device are correct.

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