NCLEX-PN
MSC NCLEX Physiological Integrity Pharmacological and Parenteral Therapies Questions
Extract:
Question 1 of 5
The nurse observes a colleague about to administer an IM injection to the 12-month-old. Which intervention requires the nurse to intervene?
Correct Answer: C
Rationale: A: No more than 2 mL of fluid should be injected into a muscle. B: The appropriate needle length for an IM injection for children ages 2 to 12 months is 1 inch and 1% inch for toddlers. C: Use of the dorsal gluteal site is not recommended due to a high risk of nerve damage. D: Use of lidocaine/prilocaine cream (EML
A) to numb the area is suggested when time allows but is not required.
Question 2 of 5
The client has been receiving clonidine 0.1 mg via transdermal patch once every 7 days. The NA removes the patch with morning cares. Eight hours later, the nurse discovers that the clonidine patch is no longer present. Which assessment finding should be most concerning to the nurse?
Correct Answer: C
Rationale: A: Although a skin tear is concerning and may have occurred during removal, it is not the most concerning. B: Headache can occur from the abrupt removal of clonidine but is not the most concerning. C: Clonidine (Catapres) is an antihypertensive medication. Rebound hypertension occurs from abrupt withdrawal. Immediate intervention is required to lower the BP. D: Tachycardia is an adverse effect of clonidine.
Question 3 of 5
The HCP prescribes 5% albumin for four clients. The nurse should consult with the HCP if 5% albumin is prescribed for which client?
Correct Answer: C
Rationale: A: Persons of the Catholic faith usually accept blood and blood products. B: Persons of African American ethnicity usually accept blood and blood products. C: Albumin is a blood derivative obtained by fractionating pooled venous and placental human plasma. Persons of the Jehovah's Witnesses faith usually do not accept RBCs; some do not accept blood products such as albumin or plasma. D: Persons of Asian ethnicity usually accept blood and blood products.
Question 4 of 5
The nurse has completed swaddling the 2-month-old infant, prepared supplies to cannulate the scalp vein for an IV infusion, and cleansed and shaved the hair at the site over the temporal bone. Place the remaining steps in the order that they should be performed by the nurse.
Order the Items
Source Container
Correct Answer: C,A,D,B,F,E
Rationale: C: Apply lidocaine/prilocaine (EML
A) cream to the site selected and unswaddle the infant after the cream application. An anesthetic cream will numb the site and help reduce the infant's pain during insertion. The infant does not need to remain swaddled while the cream reaches its therapeutic effectiveness in about an hour. A: Return in 60 minutes and reswaddle the infant in a mummy restraint. It takes about an hour for the lidocaine/prilocaine cream to reach its therapeutic effectiveness. The infant should be reswaddled to minimize movement during insertion. D: Cleanse the shaved area with an antiseptic solution. Cleansing the area with an antiseptic solution will help prevent inadvertent introduction of microorganisms into the vascular system. B: With an assistant holding the infant's head, insert a scalp vein needle and observe for blood return. Movement of the infant's head can result in loss of the vein access or a needle-stick injury to the infant or nurse. F: Initiate the infusion and cover the infusion needle with a gauze dressing. Once the vein has been successfully cannulated, the site can be dressed and IV fluids started. E: Remove the mummy restraint after initiating the infusion and comfort the infant. The mummy restraint is no longer needed after the IV catheter has been successfully inserted into a scalp vein.
Question 5 of 5
The 11-year-old with type 1 DM is learning to use insulin pens for basal-bolus insulin therapy with both a very-long-acting insulin and rapid-acting insulin. Which action by the child should indicate to the nurse that additional teaching is needed?
Correct Answer: C
Rationale: A:
To ensure that the medication is administered with the insulin pens, the pen is held in place for 10 seconds after delivery of the medication. This action is correct. B: Insulin lispro (Humalog) is rapid-acting insulin with an onset of 5 to 10 minutes. This action is correct. C: Insulin glargine (Lantus) is very-long-acting insulin administered once daily and is not used for covering the number of carbohydrates eaten. This action indicates the child needs additional teaching. D: The rapid-acting insulin lispro (Humalog) is not needed if the glucose level is WNL. Turkey does not contain carbohydrates; insulin is administered to cover only the carbohydrates eaten. This action is correct.