NCLEX-PN
NCLEX Trainer Test 5 Questions
Extract:
At 11 AM a patient returned to the nursing unit from the postanesthesia care unit (PACU) following a hemorrhoidectomy. At noon the patient complains of pain. The physician has ordered meperidine (Demerol) 50 mg IV q 3-4 hrs. The chart indicates that the patient was given Demerol 50 mg IV at 9:15 AM.
Question 1 of 5
The nurse should
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) no reason to call the physician (2) can't change amount of medication ordered by physician (3) medication is ordered every 3 to 4 hours, should not wait if patient needs medication after 3 hours (4) correct-give patient the medication as ordered
Extract:
Question 2 of 5
An obstetrical client elects to have epidural anesthesia with Marcaine. After the epidural anesthesia is given, the nurse should monitor the client for signs of:
Correct Answer: C
Rationale: Marcaine (bupivacaine) can cause vasodilation, leading to postural hypotension. Seizures, respiratory depression, and hematuria are less common.
Extract:
A client who is receiving hydralazine (Apresoline) q6h has a blood pressure of 90/60.
Question 3 of 5
Which of the following nursing actions would be MOST appropriate?
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Is there an appropriate assessment? No. Determine the outcome of the implementations. (1) correct-BP of 90/60 is too low for an additional dose of medication, withholding the medication and checking with the doctor is appropriate (2) assessment, appropriate nursing action for a client on an antihypertensive that has diuretic effects due to increased blood flow to the kidney, not a priority in this instance (3) unnecessary (4) appropriate nursing action for a client on an antihypertensive that has diuretic effects due to increased blood flow to the kidney, not a priority in this instance
Extract:
Question 4 of 5
The nurse is to administer Lanoxin(digoxin) elixir to a 6-month old with a congenital heart defect. The nurse auscultates an apical pulse rate of 100 . The nurse should:
Correct Answer: B
Rationale: A pulse of 100 in a 6-month-old is normal (80-150 bpm), so the nurse should administer digoxin . Calling the physician or holding the dose is unnecessary. Rechecking later is not standard.
Question 5 of 5
A client with MRSA is receiving Vanomycin (Vancocin) IV. If the client experiences 'red man' syndrome, the nurse should:
Correct Answer: A
Rationale: Red man syndrome is caused by rapid vancomycin infusion, leading to histamine release. Slowing the infusion and monitoring blood pressure manage symptoms. It's not normal, and discontinuing is unnecessary.