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Questions 160

NCLEX-PN

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Extract:


Question 1 of 5

The nurse is preparing to administer a unit of packed red blood cells. Which solution should be used to prime the IV tubing?

Correct Answer: A

Rationale: 0.9% sodium chloride is compatible with red blood cells and prevents hemolysis during transfusion.

Question 2 of 5

The physician orders enoxaparin (Lovenox) for a client who has been diagnosed with a blood clot. To prevent bruising, which actions by the nurse are most appropriate? Select all that apply.

Correct Answer: A,F

Rationale: Avoiding rubbing and applying gentle pressure minimize bruising at the injection site for enoxaparin.

Question 3 of 5

In an adult client, the nurse plans to administer 2 mL of medication I.M. Which technique is most accurate?

Correct Answer: C

Rationale: The deltoid muscle is appropriate for 2 mL IM injections in adults, using a 1-1.5" needle at a 90-degree angle for proper muscle penetration.

Question 4 of 5

Which action by the nurse is most appropriate while assessing the neurologic function of a client who has a freshly applied plaster cast to the lower extremity?

Correct Answer: A

Rationale: Asking the client to wiggle the toes assesses motor function, ensuring no nerve compression from the cast.

Question 5 of 5

The nurse is caring for a client receiving mechanical ventilation. Which action prevents ventilator-associated pneumonia?

Correct Answer: A

Rationale: Elevating the head of the bed reduces aspiration risk, a key factor in preventing ventilator-associated pneumonia.

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