NCLEX Questions, NCLEX RN Practice Tests Questions, NCLEX-RN Questions, Nurselytic

Questions 149

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Question 1 of 5

The nurse is assessing the laboratory results of a client scheduled to receive phenytoin (Dilantin). The Dilantin level, drawn 2 hours ago, is 30 mcg/mL. What is the appropriate nursing action?

Correct Answer: B

Rationale: A Dilantin level of 30 mcg/mL is above the therapeutic range (10-20 mcg/mL), indicating toxicity risk. The nurse should hold the dose and notify the physician for further orders.

Question 2 of 5

A client requires insertion of a nasogastric tube. When preparing the client for the procedure, the nurse should place the client in which of the following positions?

Correct Answer: A

Rationale: High Fowler's position with the head tilted forward (
A) facilitates nasogastric tube insertion by aligning the esophagus and reducing the risk of aspiration. Tilting the head backward (B,
D) or using a neutral position in semi-Fowler's (
C) is less effective for this procedure.

Question 3 of 5

The nurse is caring for a client with a long history of taking magnesium hydroxide for managing symptoms of peptic ulcer disease. Which finding in the client's medical history would be of concern to the nurse?

Correct Answer: C

Rationale: Magnesium hydroxide can cause fluid retention, worsening heart failure. Other conditions are not directly affected.

Question 4 of 5

When using restraints for an agitated/aggressive patient, which of the following statements should NOT influence the nurse’s actions during this intervention?

Correct Answer: C

Rationale: the need for restraints is based on patient’s behavioral status and condition, not the patient’s voluntary/involuntary status

Question 5 of 5

The client using a diaphragm should be instructed to:

Correct Answer: D

Rationale: Surgery, especially pelvic or abdominal, can alter pelvic anatomy, requiring the diaphragm to be resized for effective contraception.

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