Questions 149

NCLEX-RN

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Question 1 of 5

The nurse is preparing to administer a dose of morphine sulfate to a client with postoperative pain. The client’s respiratory rate is 10 breaths per minute. Which of the following actions should the nurse take?

Correct Answer: B

Rationale: a respiratory rate of 10 breaths per minute is low, and morphine can further depress respiration, so the dose should be withheld

Question 2 of 5

A client is admitted to the unit 2 hours after an injury with second-degree burns to the face, trunk, and head. The nurse would be most concerned with the client developing what?

Correct Answer: B

Rationale: Laryngeal edema is a critical concern with facial and head burns due to the risk of airway obstruction.

Question 3 of 5

The nurse is auscultating the apical pulse over the PMI (point of maximum impact). Which heart sounds would be audible?

Correct Answer: D

Rationale: S1 (mitral/tricuspid closure) and S2 (aortic/pulmonic closure) are normally audible at the PMI. S3 and S4 are less common and indicate pathology.

Question 4 of 5

A teenage client tells the nurse about her plans to be a lifeguard this summer. The nurse would be concerned if she saw the client was taking which medication? Select all that apply.

Correct Answer: B

Rationale: Isotretinoin (Accutane) causes photosensitivity, increasing sunburn risk, which is concerning for a lifeguard exposed to sunlight. Other medications do not pose significant outdoor risks.

Question 5 of 5

The nurse is taking a history from a client in an outpatient clinic. The client has been taking duloxetine (Cymbalta) for fibromyalgia. Which of the following over-the-counter medications would cause the nurse some concern if the client says she is taking it?

Correct Answer: D

Rationale: Dextromethorphan can interact with duloxetine, increasing the risk of serotonin syndrome, a potentially serious condition.

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