NCLEX Questions, NCLEX PN Practice Test Questions, NCLEX-PN Questions, Nurselytic

Questions 164

NCLEX-PN

NCLEX-PN Test Bank

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Extract:


Question 1 of 5

The nurse caring for a client with anemia recognizes which clinical manifestation as one specific for a hemolytic type of anemia?

Correct Answer: A

Rationale: The destruction of red blood cells causes the release of bilirubin, leading to the yellow hue of the skin. Answers C and D occur with anemia but are not specific to hemolytic. Answer B does not relate.

Question 2 of 5

The nurse is preparing to administer the fourth dose of vancomycin IVPB to a client with infective endocarditis. Which intervention should the nurse anticipate?

Correct Answer: D

Rationale: Vancomycin requires therapeutic drug monitoring to ensure efficacy and prevent toxicity. Obtaining a serum trough level 15-30 minutes before the fourth dose (
D) is standard to guide dosing adjustments. A new IV line (
A) is unnecessary unless the current line is compromised. Antiemetics (
B) are not routinely needed. Infusion over 60 minutes (
C) is typical to prevent red man syndrome, not 30 minutes.

Question 3 of 5

The nurse is caring for a client who received albuterol 30 minutes ago for an acute exacerbation of asthma. It would indicate that the medication has been effective if the client experiences a decreased

Correct Answer: A

Rationale: Albuterol, a bronchodilator, relieves bronchospasm in asthma, reducing airway resistance. Decreased use of accessory muscles (
A) indicates improved breathing and oxygenation, a direct sign of albuterol's effectiveness. Changes in blood pressure (
B), anxiety (
C), or heart rate (
D) are not primary indicators of albuterol's effect, as they may be influenced by other factors like the stress of the attack or concurrent medications.

Question 4 of 5

Which activity is appropriate to assign to a certified nursing assistant?

Correct Answer: C

Rationale: Assisting with ADLs is within a CNA's scope, unlike evaluating vitals, monitoring feedings, or discussing instructions, which require nursing judgment.

Question 5 of 5

The nurse is caring for a client with immune thrombocytopenic purpura. Which client statements indicate a need for further teaching? Select all that apply.

Correct Answer: C,E

Rationale: ITP increases bleeding risk. Using a safety razor (
C) risks cuts, and ibuprofen (E) inhibits platelets, both requiring further teaching. Soft toothbrush (
A), safe walking (
B), and docusate (
D) are appropriate.

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