Questions 150

NCLEX-RN

NCLEX-RN Test Bank

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Question 1 of 5

The nurse coordinates with the laboratory staff to have the gentamicin trough serum level drawn. At what time should the blood be drawn in relation to the administration of the I.V. dose of gentamicin sulfate [Garamycin]?

Correct Answer: D

Rationale: The trough level, which measures the lowest drug concentration, is drawn just before the next dose to ensure the drug is within a therapeutic range and to avoid toxicity.

Question 2 of 5

The nurse should instruct the parents of a school-age child with hemophilia to implement which of the following when the child develops bleeding into a joint? Select all that apply.

Correct Answer: A,C

Rationale: Resting the joint and administering factor VIII therapy are critical to manage bleeding in hemophilia. Heat and physical therapy may worsen bleeding, and topical antifibrinolytics are not effective for joint bleeds.

Question 3 of 5

To protect a client who has received tissue plasminogen activator (t-PA, or Activase) therapy, the nurse should:

Correct Answer: B

Rationale: Maintaining pressure on arterial puncture sites for 10 seconds minimizes bleeding risk, critical after t-PA due to its thrombolytic effects.

Question 4 of 5

A client with diabetes is explaining to the nurse how she will care for her feet at home. Which statement indicates that the client understands proper foot care?

Correct Answer: D

Rationale: Thorough drying prevents moisture-related infections, critical for diabetic foot care to avoid complications like ulcers.

Question 5 of 5

The nurse is assessing a neonate at 5 minutes after birth. The nurse records the Apgar score based on the findings in the chart below. The nurse compares these findings to the Apgar score obtained at birth, as determined by the findings in the chart below. What should the nurse do next?

Correct Answer: B

Rationale: Without specific Apgar score data, the standard action is to continue assessing the neonate, as Apgar scores at 5 minutes guide ongoing monitoring unless critical findings are present.

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