Questions 158

NCLEX-RN

NCLEX-RN Test Bank

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Question 1 of 5

The child with iron poisoning is given IV deferoxamine mesylate (Desferal). Following administration, the child suffers hypotension, facial flushing, and urticaria. The initial nursing intervention would be to:

Correct Answer: B

Rationale: The IV line should not be discontinued because other IV medications will be needed. Stop the medication and begin a normal saline infusion. The child is exhibiting signs of an allergic reaction and could go into shock if the medication is not stopped. The line should be kept opened for other medication. Taking vital signs and reporting to the physician is not an adequate intervention because the IV medication continues to flow. Assessing urinary output and, if it is 30 mL an hour, maintaining current treatment is an inappropriate intervention owing to the child's obvious allergic reaction.

Question 2 of 5

Newborns are routinely screened for phenylketonuria. The nursery nurse ensures that this screening test is performed:

Correct Answer: B

Rationale: The infant has not ingested any protein immediately after birth, which is necessary to detect excessive serum phenylalanine. It is important that the infant take in 2-3 full days of milk or formula feedings to preclude a false-negative reading. At 2-3 days of age, inadequate milk could have been ingested owing to a delay in the initial feeding. The biochemical buildup of serum phenylalanine is detectable after 2-3 days of milk or formula ingestion.

Question 3 of 5

The client is diagnosed with a hiatal hernia. Which instruction should the nurse include in the teaching plan?

Correct Answer: C

Rationale: Avoiding lying down after meals prevents acid reflux in hiatal hernia. Small meals, elevating the head of the bed, and avoiding caffeine are also recommended.

Question 4 of 5

The nurse is planning a reality orientation program for a group of clients with organic brain syndrome at the mental health center. Props that could be used for this program are:

Correct Answer: B

Rationale: This answer is incorrect. Current magazines would be appropriate. This answer is correct. Maps of the state and town and posters that depict current events in the area are appropriate props. This answer is incorrect. Kittens would be appropriate for pet therapy, not reality therapy. This answer is incorrect. Biographies depict a past, not a present, orientation.

Question 5 of 5

A 16-year-old diabetic girl has been selected as a cheerleader at her school. She asks the nurse whether she should increase her insulin when she is planning to attend cheerleading practice sessions lasting from 8 to 11 AM. The most appropriate answer would be:

Correct Answer: D

Rationale: A nurse can give this information to a client. Exercise makes insulin more efficient in moving more glucose into the cells. No more insulin is needed. Exercise makes insulin more efficient unless the diabetes is poorly controlled. Exercise makes insulin more efficient in moving more glucose into the cells.

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