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Questions 164

NCLEX-PN

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Extract:

Medication administration record
Allergies: None
Medications Time
Haloperidol: 5 mg PO, twice a day 0900, 2100
Hydrochlorothiazide: 25 mg PO, daily 0900
Omeprazole: 20 mg PO, daily 0900
Acetaminophen: 650 mg PO, PRN Every 6 hours


Question 1 of 5

The nurse on the inpatient psychiatric unit is preparing to administer 9 AM medications to a client. On assessment, the client is exhibiting signs of neuroleptic malignant syndrome. Which of the following actions should the nurse take?

Correct Answer: C

Rationale: Neuroleptic malignant syndrome is a life-threatening reaction to antipsychotics like haloperidol, requiring immediate cessation and provider notification. Acetaminophen, continuing medications, or holding hydroxyzine do not address the emergency.

Extract:


Question 2 of 5

The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, 'I will receive tissue from

Correct Answer: C

Rationale: Autografts are done with tissue transplanted from the client's own skin.

Question 3 of 5

The nurse is preparing the sterile field and supplies for a wet-to-damp dressing change. Which of the following actions by the nurse would require follow-up?

Correct Answer: D

Rationale: Using saline from a bottle opened 30 hours ago risks contamination, as sterile solutions are typically discarded after 24 hours. Keeping the field in view and placing gauze appropriately maintain sterility.

Question 4 of 5

A 4-month-old infant is being treated for talipes equinovarus (clubfoot). The nurse should include which of the following in the priority teaching plan for the parents?

Correct Answer: C

Rationale: Assisting the client to breathe into a paper bag addresses hyperventilation caused by aspirin toxicity, which can lead to respiratory alkalosis in the initial stages.

Question 5 of 5

Which nursing intervention is most critical during the administration of Acyclovir (Zovirax)?

Correct Answer: D

Rationale: Acyclovir can cause renal toxicity; encouraging fluids promotes renal perfusion and reduces risk of crystal formation in the kidneys.

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