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Questions 163

NCLEX-PN

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Extract:


Question 1 of 5

Diltiazem (Cardizem) 90 mg qid is prescribed for an adult who has angina. Which statement by the client indicates a need for further instruction?

Correct Answer: C

Rationale: Diltiazem is not typically withheld based on heart rate alone unless specified; this indicates a need for clarification on administration instructions.

Question 2 of 5

A 72-year-old woman is being treated for pneumonia. Physician's orders include an antibiotic, oxygen PRN for O2 saturation less than 90, and pulse oximetry every 4 hours. The nurse obtains a pulse oximetry reading of 82% on room air. What is the best action for the nurse to take?

Correct Answer: C

Rationale: An O2 saturation of 82% requires immediate supplemental oxygen per orders to correct hypoxia, the priority action.

Question 3 of 5

A client is receiving oxygen therapy via a nasal cannula. When providing nursing care, which of the following interventions would be appropriate?

Correct Answer: B

Rationale: Inspect the nares and ears for skin breakdown. Oxygen therapy can cause drying of the nasal mucosa. Pressure from the tubing can cause skin irritation.

Question 4 of 5

The nurse would expect the cystic fibrosis client to receive supplemental pancreatic enzymes along with a diet

Correct Answer: A

Rationale: High in carbohydrates and proteins. This diet supports energy needs and compensates for malabsorption in cystic fibrosis.

Extract:

Laboratory Reference Ranges
Glucose – Fasting

70–110 mg/dL
(3.9–6.1 mmol/L)


Question 5 of 5

A client with type 1 diabetes is prescribed NPH insulin before breakfast and dinner. Although the client reports feeling well, the 6 AM fasting blood glucose is 60 mg/dL. Which action should the nurse recommend to the client?

Correct Answer: B

Rationale: A fasting blood glucose of 60 mg/dL indicates hypoglycemia risk with NPH insulin, which peaks overnight. A bedtime snack prevents nocturnal hypoglycemia. Ketones are checked for hyperglycemia, increased carbohydrates may cause hyperglycemia, and skipping doses disrupts control.

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