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Questions 163

NCLEX-PN

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Extract:


Question 1 of 5

The nurse in the emergency department is caring for a client who sustained blunt force head trauma and is experiencing blurry vision. The nurse should suspect the client has sustained injury to the

Correct Answer: B

Rationale: Blurry vision post-head trauma suggests injury to the occipital lobe , which processes visual information. Temporal , parietal , and frontal lobes manage other functions.

Question 2 of 5

A 72-year-old woman is being treated for pneumonia. Physician's orders include an antibiotic, oxygen PRN for O2 saturation less than 90, and pulse oximetry every 4 hours. The nurse obtains a pulse oximetry reading of 82% on room air. What is the best action for the nurse to take?

Correct Answer: C

Rationale: An O2 saturation of 82% requires immediate supplemental oxygen per orders to correct hypoxia, the priority action.

Question 3 of 5

The physician has ordered a sterile urine specimen to be collected from a client who has a Foley catheter. To obtain a sterile urine specimen, the nurse should:

Correct Answer: D

Rationale: Withdrawing from the catheter port with a syringe ensures a sterile specimen. Other methods risk contamination.

Question 4 of 5

The client has been receiving garamycin 65 mg IVPB every 8 hours for the past 6 days. Which lab result indicates an adverse reaction to the medication?

Correct Answer: D

Rationale: Garamycin (gentamicin) is an aminoglycoside antibiotic that can cause nephrotoxicity. A serum creatinine level of 2.0 mg/dL is elevated (normal range is approximately 0.6-1.2 mg/dL), indicating potential kidney damage, an adverse reaction. Answers A, B, and C represent normal or unrelated lab values.

Extract:

Laboratory Reference Range
Glucose (fasting)
70-110 mg/dL
(3.9-6.1 mmol/L)


Question 5 of 5

The nurse has received information from unlicensed assistive personnel about assigned client situations. Which of the following situations should the nurse address first?

Correct Answer: D

Rationale: A full sharps container poses an immediate safety hazard and must be addressed first. Normal glucose , a discarded void , and procedure clarification are less urgent.

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