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Questions 227

NCLEX-PN

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Extract:


Question 1 of 5

The nurse is caring for an adult who had a transsphenoidal hypophysectomy earlier today. The client is now on the surgical unit after an uneventful stay in the postanesthesia care unit. How should the nurse position the client?

Correct Answer: C

Rationale: Semi-reclining reduces intracranial pressure and prevents cerebrospinal fluid leakage post-transsphenoidal hypophysectomy. Supine increases leakage risk, and upright or side-lying are less optimal.

Question 2 of 5

A nurse assigned to the rural health clinic is to administer a Mantoux test to a group of factory workers. The nurse should administer the test in each client's:

Correct Answer: C

Rationale: The Mantoux test is administered intradermally in the forearm for accurate reading of the tuberculin reaction. Thigh , buttock , and upper arm are incorrect sites.

Question 3 of 5

The nurse is preparing to administer a dose of enoxaparin (Lovenox) to a client with a pulmonary embolism. Which of the following actions should the nurse take?

Correct Answer: C

Rationale: Enoxaparin, a low-molecular-weight heparin, is administered subcutaneously in the abdomen (avoiding a 2-inch radius around the umbilicus) to ensure proper absorption. Deltoid injection (
A) is incorrect, massaging (
B) risks hematoma, and dilution (
D) is unnecessary.

Extract:

The nurse assesses a patient's IV site and finds that it is red, hot, and tender to touch.


Question 4 of 5

The most appropriate first nursing action is:

Correct Answer: A

Rationale: Signs of phlebitis or infection require stopping the infusion and removing the IV to prevent further complications.

Extract:


Question 5 of 5

A patient is prescribed nitroglycerin for angina. Which of the following instructions should the nurse include?

Correct Answer: C

Rationale: Nitroglycerin is placed sublingually for rapid absorption to relieve angina. Swallowing or taking with water delays action, and meal timing is irrelevant.

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