Questions 151

NCLEX-RN

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Question 1 of 5

The nurse calls the primary health care provider to express concerns about a chemotherapeutic medication dose prescribed by the primary health care provider being too high. The primary health care provider office informs the nurse that the primary health care provider has left town and will not be available for several days. What action should the nurse take next to assure client safety?

Correct Answer: C

Rationale: If the nurse believes a primary health care provider's prescription to be in error, the nurse must clarify the dosage with the client's primary health care provider or the primary health care provider's substitute before administering the medication. Rescheduling the client's chemotherapy is incorrect. Chemotherapy must be administered on a specific schedule for maximum effect with minimum adverse effects. Additionally, only a prescriber can withhold or reschedule chemotherapy. Withholding the medication until the partner makes rounds is incorrect. Chemotherapy agents must be administered in the proper combinations or sequence in order to be effective. Checking with the pharmacist can assist the nurse in determining whether the dose prescribed is incorrect, but the nurse or pharmacist cannot alter the dose without a revised prescription from a licensed primary health care provider with prescriptive authority.

Question 2 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.

Question 3 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 4 of 5

On the night before a 58-year-old wife and mother is to have a lobectomy for lung cancer, she remarks to the nurse, 'I am so scared of this cancer. I should have quit smoking years ago. Now I've brought all this fear and sadness on myself and now my family.' The nurse should tell the client:

Correct Answer: D

Rationale: Acknowledging the client's fear and exploring specific concerns fosters therapeutic communication, helping address her emotions effectively.

Question 5 of 5

The nurse is caring for a client who has just undergone a splenectomy. Which of the following complications should the nurse monitor for in the immediate postoperative period?

Correct Answer: A

Rationale: Splenectomy increases infection risk due to impaired immune function, requiring close monitoring.

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