Questions 151

NCLEX-RN

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Question 1 of 5

How many units of heparin would you administer subcutaneously using the below information? Doctor's order: 6,500 units of heparin subcutaneously Medication label: 4,500 units in one mL

Correct Answer: A

Rationale:
To calculate: 6,500 units ÷ 4,500 units/mL = 1.444 mL, rounded to 1.4 mL for practical administration.

Question 2 of 5

A client has been prescribed metoclopramide on a long-term basis. A home care nurse calls the primary health care provider immediately if which side effect is noted in this client?

Correct Answer: C

Rationale: Metoclopramide is a 'prokinetic' drug used to treat heartburn. If the client experiences tardive dyskinesia (rhythmic movements of the face or limbs), the nurse should withhold the medication and call the primary health care provider. These side effects may be irreversible. Excitability is not a side effect of this medication. Anxiety, irritability, and dry mouth are milder side effects that are not harmful to the client.

Question 3 of 5

The nurse is teaching an unlicensed assistive personnel about the care of clients with self-mutilation. Which of the following, if stated by the unlicensed personnel about self-mutilation, demonstrates that the teaching has been effective?

Correct Answer: C

Rationale: Self-mutilation is often a way to express intense emotions like anger or rage, indicating the assistant understands its emotional significance.

Question 4 of 5

The nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions is the highest priority to prevent ventilator-associated pneumonia?

Correct Answer: B

Rationale: Elevating the head of the bed to 30-45 degrees reduces the risk of aspiration, a key factor in preventing ventilator-associated pneumonia.

Question 5 of 5

A client has implemented dietary and other lifestyle changes to manage hypertension. The nurse determines that the client has been most successful when the client has which follow-up blood pressure reading?

Correct Answer: D

Rationale: Normal blood pressure readings are less than 120/80 mm Hg. A blood pressure reading between 120/80 mm Hg and 139/89 mm Hg is considered to be a prehypertensive state. From the readings provided in the options, the correct option identifies the most successful outcome, although the reading indicates a prehypertensive state.

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