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NCLEX-PN

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Question 1 of 5

The nurse is caring for a client with a myocardial infarction. Which finding requires the nurse's immediate action?

Correct Answer: B

Rationale: Dizzy spells. Cardiac dysrhythmias may cause a transient drop in cardiac output and decreased blood flow to the brain. Near syncope refers to lightheadedness, dizziness, temporary confusion. Such 'spells' may indicate runs of ventricular tachycardia or periods of asystole and should be reported immediately.

Question 2 of 5

After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse three hours after admission, should be reported to the physician?

Correct Answer: B

Rationale: Clear fluid draining from the ear suggests cerebrospinal fluid (CSF) leakage, indicating a rupture of the meninges, which poses a risk of meningitis or other complications in a head injury. This must be reported immediately. Eyelid edema (
A) and minor bleeding (
C) are less urgent, and withdrawal to pain (
D) is consistent with the initial assessment.

Question 3 of 5

A client is scheduled for an Intravenous Pyelogram (IVP). In order to prepare the client for this test, the nurse would

Correct Answer: C

Rationale: Administer a laxative to the client the evening before the examination. Bowel prep is important because it will allow greater visualization of the bladder and ureters.

Question 4 of 5

Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a client's uremia. Which finding signals a significant problem during this procedure?

Correct Answer: B

Rationale: An increased WBC count indicates infection, probably resulting from peritonitis, which may have been caused by insertion of the peritoneal catheter into the peritoneal cavity. Peritonitis can cause the peritoneal membrane to lose its ability to filter solutes; therefore, peritoneal dialysis would no longer be a treatment option for this client. Hyperglycemia occurs during peritoneal dialysis because of the high glucose content of the dialysate; it's readily treatable with sliding-scale insulin. A potassium level of 3.8 mEq/L is an acceptable value. An HCT of 35% is lower than normal. However, in this client, the value isn't abnormally low because of the daily blood samplings. A lower HCT is common in clients with chronic renal failure because of the lack of erythropoietin.

Question 5 of 5

A client is taking hydrocodone (Vicodin) for chronic back pain. The client has required an increase in the dose and asks whether this means he is addicted to Vicodin. The nurse should base her reply on the knowledge that:

Correct Answer: A

Rationale:
Tolerance, requiring higher doses for the same effect, is common with long-term opioid use and does not equate to addiction. Addiction involves psychological dependence, not described here. Psychosocial Integrity

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