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Questions 227

NCLEX-PN

NCLEX-PN Test Bank

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Extract:

Which of the following data reflects that fluid resuscitation on B.C was effective?


Question 1 of 5

Urine output of 300 cc/24H; increased BUN, increased Na+ level.

Correct Answer: C

Rationale: Urine output of 30 cc/hour, decreased BUN, and decreased Na+ level reflect kidney perfusion, indicating effective fluid resuscitation.

Extract:


Question 2 of 5

The multidisciplinary team decides to implement behavior modification with a client. Which of the following nursing actions is of primary importance during this time?

Correct Answer: A

Rationale:
To implement a behavior modification plan successfully, all staff members need to be included in program development, and time must be allowed for discussion of concerns from each nursing staff member; consistency and follow-through is important to prevent or diminish the level of manipulation by the staff or client during implementation of this program. Ensuring staff compliance promotes a unified approach, which is critical for the plan’s effectiveness.

Question 3 of 5

The physician prescribes penicillin potassium oral suspension 56 mg/kg/day in four divided doses for a client with anorexia nervosa who weighs 25 kg. The medication dispensed by the pharmacy contains a dosage strength of 125 mg/5 ml. How many milliliters of solution should the nurse administer with each dose?

Correct Answer: A

Rationale:
To determine the total daily dosage, set up the following proportion: 25 kg/X = 1 kg/56 mg, X = 1,400 mg. Next, divide the daily dosage by four doses to determine the dose to administer every 6 hours: X = 1,400 mg/4 doses, X = 350 mg/dose. The adolescent should receive 350 mg every 6 hours. Lastly, calculate the volume to give for each dose by setting up this proportion: X/350 mg = 5 ml/125 mg, X = 14 ml.

Question 4 of 5

A case management clinical pathway for congestive heart failure might include all of the following except:

Correct Answer: D

Rationale: Clinical pathways include maps of care outcomes to be achieved prior to discharge or movement through a health care system. Insurance review for reimbursement is a function of an outside agency from the health care provider.

Question 5 of 5

The nurse is assessing a child admitted who has a fractured humerus. The family says the child fell. Which piece of information would cause the nurse to suspect child abuse?

Correct Answer: C

Rationale: Small round burns suggest cigarette burns, a specific sign of abuse. Frequent ER visits or bruising are concerning but less definitive; hand-holding is normal.

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