Questions 150

NCLEX-RN

NCLEX-RN Test Bank

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Question 1 of 5

Which of the following outcomes is most appropriate for a nursing diagnosis of Ineffective tissue perfusion related to interruption of arterial flow? Select all that apply.

Correct Answer: A,C,D

Rationale: Warm extremities, reduced muscle pain, and self-care participation indicate improved perfusion; respiratory outcomes are unrelated.

Question 2 of 5

A mother reports to the nurse that she cannot afford the antibiotic azithromycin (Zithromax), which was ordered by the physician for her toddler's ear infection. Which of the following is the most appropriate action by the nurse?

Correct Answer: C

Rationale: Conferring with the physician to explore a less expensive alternative medication addresses the mother's financial concern while ensuring treatment. Instructing on importance doesn't solve affordability, asking about loans is inappropriate, and a social worker may help later but isn't the first step.

Question 3 of 5

A client with a diagnosis of gout is prescribed febuxostat (Uloric). The nurse should instruct the client to:

Correct Answer: A,B

Rationale: Taking febuxostat with food reduces gastrointestinal upset, and avoiding alcohol prevents uric acid buildup.

Question 4 of 5

A client with a moderate level of anxiety is pacing quickly in the hall. As the nurse approaches, he states, 'Help me. I can't take it anymore.' Which of the following would be the best response initially?

Correct Answer: B

Rationale: Offering to talk in a quieter area de-escalates anxiety and provides a supportive environment.

Question 5 of 5

The nurse is preparing to perform a Mantoux tuberculin skin test. Which interventions apply to the administration of this test? Select all that apply.

Correct Answer: A,C,E,F

Rationale: The nurse should always explain the procedure to the client and then assess him or her for a history of a PPD reaction. The test should not be administered if the client has such a history. The nurse should use a tuberculin syringe (not a 3-mL syringe) with a 1/2-inch 26- or 27-gauge needle. The injection site on the lower dorsal surface of the forearm is cleansed with alcohol and allowed to dry. The skin is stretched taut, and 0.1 mL of solution containing 0.5 tuberculin units of PPD is injected. The injection is made just under the surface of the skin with the needle bevel facing upward to provide a discrete elevation of the skin (a wheal) 6 to 10 mm in diameter. The test area is marked to locate it for reading and the test area is read 48 to 72 hours after injection.

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