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

Questions 164

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Extract:


Question 1 of 5

The nurse is reinforcing teaching to a client being discharged on enoxaparin therapy following total knee replacement surgery. Which statement made by the nurse is most appropriate?

Correct Answer: B

Rationale: Mild bruising or redness at the injection site is a common side effect of enoxaparin, a low-molecular-weight heparin. Vitamin K restriction applies to warfarin, ibuprofen increases bleeding risk, and PT/INR monitoring is not required for enoxaparin.

Question 2 of 5

An adult is admitted for surgery today. Immediately after administering the preoperative medications of meperidine and atropine, the nurse notes that the operative permit has not been signed. Which action should the nurse take?

Correct Answer: D

Rationale: Preoperative medications like meperidine impair judgment, making consent invalid post-administration. Reporting to the physician to delay surgery ensures legal and ethical consent.

Question 3 of 5

The nurse is assessing a client with portal hypertension. Which of the following findings would the nurse expect?

Correct Answer: C

Rationale: Ascites. Portal hypertension can occur in a client with right-sided heart failure or cirrhosis of the liver. Portal hypertension can lead to ascites due to the increased portal pressure as well as a lowered colloid osmotic pressure because of low albumin. When liver functioning deteriorates, protein metabolism suffers.

Question 4 of 5

The nurse is assisting with an education conference for graduate nurses about infant CPR. Which of the following statements are appropriate to include in the teaching? Select all that apply.

Correct Answer: A,E

Rationale: Two minutes of CPR before defibrillator retrieval and assessing the brachial pulse for ≤10 seconds align with infant CPR guidelines. Compression depth is about one-third the chest, two fingers are used, and the ratio is 30:2 for a single rescuer.

Question 5 of 5

The nurse should initiate discharge planning for a client

Correct Answer: C

Rationale: Upon admission to a hospital unit or the emergency room. Early discharge planning ensures continuity of care with shorter hospital stays.

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