NCLEX Questions, NCLEX-RN Exam Questions, NCLEX-RN Questions, Nurselytic

Questions 158

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Question 1 of 5

Which statement made by the student nurse indicates the need for further teaching regarding the administration of heparin?

Correct Answer: D

Rationale: Heparin is administered subcutaneously without aspiration, as aspirating can cause tissue damage and increase bleeding risk. The other statements are correct: heparin is injected 1–2 inches from the umbilicus, massage is avoided to prevent hematoma, and PTT is monitored to assess therapeutic effect.

Question 2 of 5

The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:

Correct Answer: C

Rationale: Neonates of diabetic mothers are often large for gestational age (macrosomic) due to maternal hyperglycemia and are at risk for hypoglycemia after birth due to high insulin levels. Hyperglycemia and small size are less common.

Question 3 of 5

The nurse is completing an assessment history of a client with pernicious anemia. Which complaint differentiates pernicious anemia from other types of anemia?

Correct Answer: B

Rationale: Pernicious anemia, caused by vitamin B12 deficiency, leads to neurological symptoms like numbness and tingling due to nerve demyelination. The other symptoms are common in various anemias.

Question 4 of 5

The physician has prescribed Nexium (esomeprazole) for a client with erosive gastritis. The nurse should administer the medication:

Correct Answer: A

Rationale: Esomeprazole (Nexium) a proton pump inhibitor is most effective when taken 30 minutes before breakfast to suppress acid production before meals. Taking it with or after meals or at bedtime is less optimal for gastritis treatment.

Question 5 of 5

A 3-year-old child has had symptoms of influenza including fever, productive cough, nausea, vomiting, and sore throat for the past several days. In caring for a young child with symptoms of influenza, the mother must be cautioned about:

Correct Answer: A

Rationale: Aspirin should never be given to children with influenza because of the possibility of causing Reye's syndrome. Pepto-Bismol is also classified as a salicylate and should be avoided. Depending on the severity of symptoms, the child may be receiving IV therapy or clear liquids. The disease has a 1-3 day incubation period and affected children are most infectious 24 hours before and after the onset of symptoms. Although viral pneumonia can be a complication of influenza, this would not be an initial priority.

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