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Questions 164

NCLEX-PN

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Extract:


Question 1 of 5

The home health nurse is contributing to the plan of care for a 1-year-old client recently diagnosed with failure to thrive. Which of the following interventions should the nurse recommend including in the client's plan of care? Select all that apply.

Correct Answer: A,B,C,D

Rationale: Assessing parenting, observing feedings, monitoring growth, and reviewing intake identify causes of failure to thrive. Nasogastric tubes are not initially indicated.

Question 2 of 5

The nurse on a medical surgical unit enters a room, finds a client unresponsive with no pulse, and starts 2 minutes of CPR. The nurse receives and attaches an automated external defibrillator, but no shock is advised. Which action should the nurse perform next?

Correct Answer: C

Rationale: If no shock is advised, CPR should resume immediately with chest compressions to restore circulation.

Question 3 of 5

The nurse is preparing to administer sumatriptan to a client with a migraine headache. Which of the following findings would require follow-up prior to administering the medication?

Correct Answer: B

Rationale: Sumatriptan is contraindicated in uncontrolled hypertension due to the risk of cardiovascular events.

Question 4 of 5

An 8-month-old infant is scheduled for balloon angioplasty of a congenital pulmonic stenosis in the cardiac catheterization laboratory. Which finding could possibly delay the procedure and should be reported?

Correct Answer: D

Rationale: Severe diaper rash may increase infection risk during catheterization, potentially delaying the procedure.

Question 5 of 5

An adult is hospitalized following a myocardial infarction. While the client is receiving heparin, the nurse should have which of the following medications available?

Correct Answer: D

Rationale: Protamine sulfate is the antidote for heparin overdose, reversing its anticoagulant effects in case of bleeding.

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