Questions 150

NCLEX-RN

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Question 1 of 5

The nurse is evaluating the effectiveness of antimicrobial therapy for a client diagnosed with infective endocarditis. The nurse determines that which finding is the least reliable indicator of effectiveness?

Correct Answer: B

Rationale: A systolic heart murmur, once present in the client, will not resolve spontaneously and is therefore the least reliable indicator. Clear breath sounds are a normal finding, and in this instance could mean resolution of heart failure, if that was accompanying the endocarditis. Negative blood cultures and normothermia indicate resolution of infection.

Question 2 of 5

Which of the following is a risk factor for toxic shock syndrome (TSS)?

Correct Answer: D

Rationale: Using tampons only at night increases TSS risk due to prolonged use, allowing bacterial growth. Frequent changing and alternating with pads reduce risk.

Question 3 of 5

An intravenous dose of lorazepam is prescribed for a client. Which data from the client's history would indicate the need to consult with the primary health care provider before administering the medication?

Correct Answer: A

Rationale: Lorazepam is a benzodiazepine and is contraindicated in clients who are comatose, with preexisting central nervous system (CNS) depression, with uncontrolled severe pain, and those with narrow-angle glaucoma. It is also contraindicated if hypersensitivity or cross-sensitivity with other benzodiazepines exists. It is also not prescribed for clients who are pregnant or breast-feeding.

Question 4 of 5

A client with a history of breast cancer is prescribed tamoxifen (Nolvadex). Which side effect should the nurse teach the client to report?

Correct Answer: C

Rationale: Vaginal bleeding may indicate endometrial hyperplasia or cancer, a serious side effect of tamoxifen requiring immediate reporting.

Question 5 of 5

The nurse is caring for a client with a suspected urinary tract infection. Which symptom is most common?

Correct Answer: A

Rationale: Dysuria (painful urination) is the most common symptom of a urinary tract infection, reflecting bladder or urethral irritation.

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