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Questions 227

NCLEX-PN

NCLEX-PN Test Bank

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Extract:


Question 1 of 5

The client is being treated with intravenous Vancomycin for MRSA when the nurse notes redness of the client's neck and chest. Place in ordered sequence the actions to be taken by the nurse:

Correct Answer: B,D,C,A

Rationale: Redness suggests an allergic reaction or 'red man syndrome' from rapid vancomycin infusion. The nurse should: stop the infusion to prevent further reaction, take vital signs to assess severity, administer Benadryl if ordered, and call the doctor for further orders.

Extract:

When a patient return from the recovery room following a subtotal thyroidectomy, the nurse should immediately


Question 2 of 5

inspect the incision.

Correct Answer: D

Rationale: Thyroid surgery sometimes results in accidental removal of the parathyroid glands. A resultant hypocalcemia may lead to contraction of the glottis, causing airway obstruction; edema also causes obstruction. Having a tracheostomy set ready is critical.

Extract:


Question 3 of 5

Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Another manifestation that would most suggest necrotizing fasciitis is:

Correct Answer: C

Rationale: Severe pressurelike pain out of proportion to visible signs distinguishes necrotizing fasciitis from cellulitis. Erythema, leukocytosis, and swelling are present in both cellulitis and necrotizing fasciitis.

Extract:

A mother indicates correct understanding of postpartum discharge instructions when starting that she will take her iron supplements with:


Question 4 of 5

A mother indicates correct understanding of postpartum discharge instructions when starting that she will take her iron supplements with:

Correct Answer: D

Rationale: Orange juice enhances iron absorption due to its vitamin C content.

Extract:

The physician orders high protein, high calorie and high salt diet on Valerie.


Question 5 of 5

When ask by the patient, the nurse would explain that

Correct Answer: D

Rationale: Lack of mineralcorticoids (aldosterone) leads to a loss of sodium ions in the urine and subsequent hyponatremia, necessitating a high salt diet.

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