NCLEX Questions, NCLEX PN Practice Tests Questions, NCLEX-PN Questions, Nurselytic

Questions 164

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Extract:


Question 1 of 5

The nurse is caring for a 2-year-old who had an anaphylactic reaction to a bee sting. After the nurse reinforces teaching on applying epinephrine, which statements by the parent indicate correct understanding? Select all that apply.

Correct Answer: A,C,D,E

Rationale: Epinephrine is given for breathing difficulty, kept accessible, followed by ER visit, and can be administered through clothing. The correct site is the thigh, not the upper arm, making B incorrect.

Question 2 of 5

When monitoring an infant with a left-to-right sided heart shunt, which findings would the nurse expect during the physical assessment? Select all that apply.

Correct Answer: C,D,E

Rationale: Left-to-right shunts (e.g., VS
D) cause pulmonary overcirculation, leading to diaphoresis, murmurs, and poor weight gain. Clubbing and cyanosis are more typical of right-to-left shunts.

Question 3 of 5

While reviewing the chart of an elderly client, the nurse notes that the last recorded temperature for the preceding shift was 104°. There is no documented intervention. The nurse should:

Correct Answer: D

Rationale: Retaking the temperature verifies the current status, as the fever may have resolved. Checking orders or asking the client assumes the fever persists, and calling the nurse is impractical.

Extract:

Medication administration record
Allergies: None
Medications Time
Gabapentin: 300 mg orally, every 8 hours 0700, 1500, and 2300
Hydrocodone/acetaminophen: (5 mg/325 mg) orally, every 4 hours Every 4 hours prn
Acetaminophen: 1,000 mg IV, every 6 hours 0600, 1200, 1800, and 2400
Phenytoin: 100 mg orally, every 12 hours 0700 and 1900


Question 4 of 5

The practical nurse on the neurosurgery step-down unit is assisting the registered nurse in the care of a stable client with a closed head injury who is 1 day post-craniotomy. The practical nurse prepares to administer the 7:00 AM medications and reviews the client’s medication administration record. Which prescription prompts the practical nurse to contact the prescribing health care provider for clarification?

Correct Answer: A

Rationale: Acetaminophen 1,000 mg IV is unusual for routine post-craniotomy pain and risks overdose if combined with oral hydrocodone/acetaminophen, requiring clarification. Other medications are standard.

Extract:

Exhibit 1
Medication administration record

Allergies: No known drug allergies

Medication Time
Insulin NPH: 75 units subcutaneously, twice daily 0800, 2000
Insulin lispro: sliding scale dosing, before meals and at bedtime 0800, 1130, 1730, 2100

Exhibit 2
Laboratory results and reference ranges

Sodium
136-145 mEq/L
(136-145 mmol/L) 141 mEq/L
(141 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L) 3.0 mEq/L
(3.0 mmol/L)
Glucose (fasting)
70-110 mg/dL
(3.9-6.1 mmol/L) 328 mg/dL
(18.2 mmol/L)





Question 5 of 5

The nurse is preparing to administer medications scheduled for 0800 to a client with type 1 diabetes mellitus. After reviewing the client's morning laboratory test results, which of the following actions would be a priority for the nurse to take?

Correct Answer: B

Rationale: Abnormal lab results (e.g., severe hypo/hyperglycemia) require provider notification to adjust treatment. Administering insulin, checking ketones, or rechecking glucose are secondary without specific lab values.

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