NCLEX RN Practice Questions Quizlet - Nurselytic

Correct Answer: D

Rationale: A platelet count of 25,000/microliter indicates severe thrombocytopenia, which increases the risk of bleeding. It is crucial to initiate bleeding precautions, including regularly checking for signs of bleeding such as examining urine and stool for blood. Monitoring for fever every 4 hours (
Choice
A) should be included for neutropenic precautions, not specifically related to platelet count. Requiring visitors to wear respiratory masks and protective clothing (
Choice
B) is more relevant for patients with airborne precautions. Considering transfusion of packed red blood cells (
Choice
C) is not indicated for low platelet count but is more appropriate for managing anemia or low hemoglobin levels.

Correct Answer: A

Rationale: The correct answer is 'Blood pressure 94/60 mm Hg.' Both digoxin and metoprolol decrease the heart rate. Metoprolol specifically affects blood pressure.
Therefore, the heart rate and blood pressure need to be within normal range (HR 60-100 bpm; systolic BP above 100 mm Hg) to safely administer both medications. A blood pressure of 94/60 mm Hg indicates hypotension, which could be exacerbated by metoprolol, necessitating immediate reporting to the healthcare provider.

Choices B, C, and D are within normal limits and do not pose immediate risks related to the administration of these medications.

Correct Answer: B

Rationale: A client experiencing an anaphylactic reaction will likely present with rash or hives, swelling of the lips, face, or tongue, hypotension, or dyspnea. In this scenario, the client is showing signs of anaphylaxis with dyspnea, chest tightness, hives, hypotension, and swelling of the lips and tongue. The next appropriate action would be to administer 0.3 mg of 1:1000 epinephrine intramuscularly. Epinephrine helps relax the muscles of the airway, improve breathing, and increase oxygenation, which is crucial in managing anaphylaxis. Starting an IV and administering fluids can be important but not the immediate priority. Diphenhydramine may be used as an adjunct therapy but should not delay the administration of epinephrine in the acute phase of anaphylaxis. Monitoring the client without providing immediate treatment can lead to a worsening of the anaphylactic reaction, potentially resulting in a life-threatening situation.

Correct Answer: C

Rationale: The symptoms of weight gain and poor temperature tolerance in an elderly male suggest a potential thyroid dysfunction. Thyroid function tests are crucial in differentiating between hyperthyroidism, hypothyroidism, and a euthyroid state. These tests involve measuring the serum levels of thyroid hormones T3 and T4, also known as thyroxine, to evaluate thyroid function accurately. A complete blood count (
Choice
A) would not directly address the symptoms presented. An electrocardiogram (
Choice
B) assesses heart activity and would not be the primary test for these symptoms. A CT scan (
Choice
D) provides detailed images of internal organs and structures, which would not be the initial investigation for the described symptoms.

Correct Answer: C

Rationale: A client with a new colostomy requires education on proper colostomy care. Waiting 30 minutes after irrigating to replace the colostomy bag is unnecessary. The client may reapply the bag once the skin is dry. Cleaning the skin around the ostomy site with soap and water, irrigating the stoma regularly to prevent gas and odor buildup, and changing the bag when it is one-third to one-fourth full are appropriate actions.
Therefore, the statement indicating the need for more education is the one suggesting a specific time interval for bag replacement after irrigation.