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Questions 227

NCLEX-PN

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Extract:

After the patient has refused the medication, the next step taken by the nurse will be:


Question 1 of 5

Document the patient's refusal.

Correct Answer: B

Rationale: Exploring the reason for refusal helps address concerns and promote adherence.

Extract:


Question 2 of 5

An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting:

Correct Answer: B

Rationale:
To reverse hypoglycemia, the American Diabetes Association recommends ingesting 10 to 15 g of a simple carbohydrate, such as three to five pieces of hard candy, two to three packets of sugar (4 to 6 tsp), or 4 oz of fruit juice. If necessary, this treatment can be repeated in 15 minutes. Ingesting only 2 to 5 g of a simple carbohydrate may not raise the blood glucose level sufficiently. Ingesting more than 15 g may raise it above normal, causing hyperglycemia.

Extract:

Rosemarie is 24 years old, G1P0, admitted with a diagnosis of Multiple Sclerosis.


Question 3 of 5

The nurse observes indications of positive response from treatments and signs that the patient is recovering from the disease by which of the following assessment data?

Correct Answer: D

Rationale: Multiple Sclerosis temporarily affects both sensory and motor functions. Being able to walk with a stable gait is a sign that the motor function is returning to normal.

Extract:


Question 4 of 5

The nurse is working in a high risk antepartum clinic. A 40 year-old woman in the first trimester gives a thorough health history. Which information should receive priority attention by the nurse?

Correct Answer: D

Rationale: Over-the-counter drugs are a possible danger in early pregnancy. A report by the client that she has taken medications should be followed up immediately.

Question 5 of 5

The nurse is caring for a client who underwent a mastectomy 24 hours ago. Which of the following interventions should the nurse prioritize?

Correct Answer: A

Rationale: Encouraging arm exercises prevents lymphedema and restores mobility post-mastectomy. Dependent positioning (
B) increases edema, heating pads (
C) risk tissue damage, and fluid restriction (
D) is unnecessary and harmful.

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