NCLEX Questions, NCLEX PN Practice Test Questions, NCLEX-PN Questions, Nurselytic

Questions 164

NCLEX-PN

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Extract:


Question 1 of 5

The nurse is preparing to administer the fourth dose of vancomycin IVPB to a client with infective endocarditis. Which intervention should the nurse anticipate?

Correct Answer: D

Rationale: Vancomycin requires therapeutic drug monitoring to ensure efficacy and prevent toxicity. Obtaining a serum trough level 15-30 minutes before the fourth dose (
D) is standard to guide dosing adjustments. A new IV line (
A) is unnecessary unless the current line is compromised. Antiemetics (
B) are not routinely needed. Infusion over 60 minutes (
C) is typical to prevent red man syndrome, not 30 minutes.

Question 2 of 5

The nurse caring for a client with anemia recognizes which clinical manifestation as one specific for a hemolytic type of anemia?

Correct Answer: A

Rationale: The destruction of red blood cells causes the release of bilirubin, leading to the yellow hue of the skin. Answers C and D occur with anemia but are not specific to hemolytic. Answer B does not relate.

Question 3 of 5

Which situations require that the nurse report to an appropriate authority? Select all that apply.

Correct Answer: B,C,D,E

Rationale: Gonorrhea (
B) and syphilis (E) are reportable diseases, regardless of HIPAA. Suspected abuse in a teenager (
C) or elderly client (
D) mandates reporting, despite provider or client denial. Cupping (
A) is a cultural practice, not abuse.

Question 4 of 5

The nurse is observing a staff member preparing regular insulin and NPH insulin in 1 syringe. The nurse should intervene if the staff member is observed

Correct Answer: A

Rationale: When mixing regular and NPH insulin, regular (clear) insulin is drawn first to prevent contamination with NPH (cloudy) insulin, which could alter its action. Drawing NPH after regular (
A) is incorrect and requires intervention. Injecting air into vials (
B) follows the same order (NPH then regular), which is correct. Needle contact with the vial (
C) is poor technique but less critical than incorrect insulin order.

Question 5 of 5

The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:

Correct Answer: C

Rationale: The client should leave the medication in the brown bottle because light deteriorates the medication. The supply should be replenished every six months, so answer A is incorrect. One tablet should be taken every five minutes times three, so answer B is incorrect. If the pain does not subside, the client should report to the emergency room. The medication should be taken sublingually and should not be crushed, so answer D is incorrect.

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