NCLEX Questions, NCLEX PN Practice Tests Questions, NCLEX-PN Questions, Nurselytic

Questions 164

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Extract:


Question 1 of 5

The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring?

Correct Answer: D

Rationale: Pitting edema indicates fluid overload, a potential mannitol complication due to fluid shifts. High urine output is expected, and improving Glasgow Coma Scale is a therapeutic effect.

Question 2 of 5

Because an adult is scheduled for a cystoscopy, the nurse should plan to do which of the following immediately prior to the procedure?

Correct Answer: C

Rationale: Cystoscopy may involve iodine-based contrast; shellfish allergies suggest iodine sensitivity, requiring verification. NPO is not needed, claustrophobia is irrelevant, and fluids are not prioritized immediately before.

Question 3 of 5

The nurse is caring for a client with type 2 diabetes mellitus who is receiving a thiazolidinedione. Which of the following findings would require immediate follow-up?

Correct Answer: A

Rationale: Thiazolidinediones (eg, rosiglitazone, pioglitazone) are oral antidiabetic medications used to manage hyperglycemia in clients with type 2 diabetes mellitus. Thiazolidinediones increase the sensitivity of insulin receptors, which improves insulin efficacy and prevents large rises in blood glucose after meals. It is a priority for the nurse to report signs of heart failure (eg, bilateral pitting edema, rapid weight gain, crackles) to the health care provider because thiazolidinediones can cause heart failure due to fluid retention. The client may require a lower thiazolidinedione dose or therapy with a different oral antidiabetic agent (eg, metformin).

Extract:

Exhibit 1
Medication administration record

Allergies: No known drug allergies

Medication Time
Insulin NPH: 75 units subcutaneously, twice daily 0800, 2000
Insulin lispro: sliding scale dosing, before meals and at bedtime 0800, 1130, 1730, 2100

Exhibit 2
Laboratory results and reference ranges

Sodium
136-145 mEq/L
(136-145 mmol/L) 141 mEq/L
(141 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L) 3.0 mEq/L
(3.0 mmol/L)
Glucose (fasting)
70-110 mg/dL
(3.9-6.1 mmol/L) 328 mg/dL
(18.2 mmol/L)





Question 4 of 5

The nurse is preparing to administer medications scheduled for 0800 to a client with type 1 diabetes mellitus. After reviewing the client's morning laboratory test results, which of the following actions would be a priority for the nurse to take?

Correct Answer: B

Rationale: Abnormal lab results (e.g., severe hypo/hyperglycemia) require provider notification to adjust treatment. Administering insulin, checking ketones, or rechecking glucose are secondary without specific lab values.

Extract:

Home Medications

Vital signs

Temperature 98.5 F (36.9 C)
Blood pressure 110/74 mm Hg
Heart rate 68/min
Respirations 16/min
SpO2 97% on room air
Medication Prescription
Medication prescription

Clopidogrel: 75 mg PO, daily
Metoprolol XL: 50 mg PO, daily
Furosemide: 40 mg PO, twice daily
Fish oil: 4 g PO, daily

Intake and Output Record
Intake and output record

Time Oral Intake Output
0700 200 mL
0800 125 mL
1000 100 mL 250 mL
1200 200 mL 250 mL
1500 150 mL 375 mL


Question 5 of 5

The nurse is caring for a client with coronary artery disease and heart failure. Which of the following findings would require immediate follow-up?

Correct Answer: C

Rationale: Hypokalemia (serum potassium <3.5 mEq/L [<3.5 mmol/L]) is a common adverse effect of potassium-wasting diuretics (eg,furosemide) that may cause leg cramps, muscle weakness, or ECG changes. Unmanaged hypokalemia can lead to lethal cardiac dyshythmias (eg, ventricular fibrillation, torsades de pointes) and paralysis.
Therefore, the nurse should immediately notify the health care provider of symptoms of hypokalemia

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