Questions 151

NCLEX-RN

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Question 1 of 5

The nurse is preparing to administer a dose of warfarin (Coumadin) to a client. The client's International Normalized Ratio (INR) is 4.0. What should the nurse do?

Correct Answer: B

Rationale: An INR of 4.0 is above the therapeutic range (2-3), indicating a risk of bleeding, so the nurse should hold the dose and notify the physician.

Question 2 of 5

The nurse is caring for a client who has just undergone a splenectomy. Which of the following complications should the nurse monitor for in the immediate postoperative period?

Correct Answer: A

Rationale: Splenectomy increases infection risk due to impaired immune function, requiring close monitoring.

Question 3 of 5

The nurse is caring for a neonate with jaundice receiving phototherapy. Which action is most important?

Correct Answer: A

Rationale: Covering the neonate's eyes protects them from retinal damage due to phototherapy light exposure.

Question 4 of 5

When developing the plan of care for a 12-year-old child who is to receive 48 hours of chemotherapy that is associated with nausea and vomiting, at which of the following times should the nurse anticipate administering an antiemetic?

Correct Answer: B

Rationale: Administering an antiemetic 30 minutes before chemotherapy and every 4-6 hours prophylactically minimizes nausea and vomiting.

Question 5 of 5

A schoolteacher asks the nurse whether all the children at school need treatment after exposure to a 7-year-old child with bacterial meningitis. The nurse responds that chemoprophylaxis should be given to:

Correct Answer: B

Rationale: Chemoprophylaxis is recommended for household and close contacts of a child with bacterial meningitis to prevent secondary cases, not the entire school or community.

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