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Questions 227

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NCLEX-PN Test Bank

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Extract:


Question 1 of 5

The nurse is caring for a client with a history of bipolar disorder who is prescribed lithium. Which of the following laboratory values should the nurse monitor?

Correct Answer: A

Rationale: Lithium can cause hyponatremia, and monitoring serum sodium ensures safe levels (therapeutic lithium range: 0.6–1.2 mEq/L). Glucose (
B), calcium (
C), and hemoglobin (
D) are not directly affected by lithium therapy.

Question 2 of 5

A nurse's neighbor complains of severe right flank pain. She explains that it began during the night, but she was able to take acetaminophen (Tylenol) and return to bed. When she awoke, the pain increased in intensity. How should the nurse intervene?

Correct Answer: C

Rationale: The nurse should advise the neighbor to seek medical attention. Explaining that she can't give medical advice might cause a delay in treatment. It's beyond the nurse's scope of practice to suggest that the neighbor might need surgery. Telling the neighbor she'll be fine might also delay treatment, and it isn't a professional response.

Extract:

B.C. is a 14-yr-old boy who was brought to the ER after he had sustained flame burns. He had been wearing masquerade costume during Halloween celebration when his costume was set ablaze by the lighted candles in the party room. He extinguished the fire by rolling on the floor. On admission, resuscitation was commenced with intravenous fluids, antibiotics, and wound dressing. On examination he was found to be a young man, not pale, but febrile (body temperature, 37.8°C). He was tachypneic, RR 26 per min, with audible breath sounds bilaterally. Burn assessment revealed a total body surface area involved of 30%, with mixed-thickness burns sparing some patchy areas of the back and the right upper limb. B.C. anterior chest was affected.


Question 3 of 5

For the first 24 hours after hospitalization, the nurse should primarily observe him for

Correct Answer: C

Rationale: Inhalation burns are usually present with facial burns, regardless of the depth; the immediate threat to life is asphyxia from irritation and edema of the respiratory passages and lungs.

Extract:


Question 4 of 5

A woman has just started receiving external radiation therapy. When the nurse enters the client's room, she notes that the client is scrubbing the area vigorously with soap and water. When asked about her actions, the woman replies that she is trying to get rid of the ugly purple marks. What is the best action for the nurse at this time?

Correct Answer: A

Rationale: Radiation marks guide precise targeting; explaining their necessity prevents removal and ensures effective treatment.

Extract:

A patient with Alzheimer's disease is admitted with suspected dehydration after his daughter reports that he's refused to drink anything for the past 3 days.


Question 5 of 5

Which lab result is most expected with dehydration?

Correct Answer: B

Rationale: Hypernatremia (elevated sodium) is expected in dehydration due to water loss.

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