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Questions 163

NCLEX-PN

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Extract:


Question 1 of 5

Four clients arrive in the urgent care clinic. Which does the nurse anticipate to be the priority for intervention?

Correct Answer: A

Rationale: The child who is confused and irritable with missing glyburide pills suggests a potential hypoglycemic emergency due to sulfonylurea overdose, which requires immediate intervention to prevent severe complications like seizures or coma.

Question 2 of 5

A client is scheduled for a percutaneous transluminal coronary angioplasty (PTCA). The nurse knows that a PTCA is the

Correct Answer: C

Rationale: PTCA is performed to improve coronary artery blood flow in a diseased artery. It is performed during a cardiac catheterization.

Question 3 of 5

The nurse walks into a client's room and finds the client lying still and silent on the floor. The nurse should first

Correct Answer: C

Rationale: Establish that the client is unresponsive. This is the first step in CPR to determine the need for further action.

Question 4 of 5

A client diagnosed with cirrhosis is started on lactulose (Cephulac). The main purpose of the drug for this client is to

Correct Answer: B

Rationale: Lactulose blocks the absorption of ammonia from the GI tract and secondarily stimulates bowel elimination.

Question 5 of 5

A new graduate nurse is administering enoxaparin to a client. Which action indicates the need for further orientation by the nurse preceptor?

Correct Answer: B

Rationale: Ejecting the air bubble in an enoxaparin syringe is incorrect, as the bubble ensures complete dose delivery and prevents leakage. Other actions (A, C,
D) are correct for subcutaneous administration.

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