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NCLEX-RN Question of the week

 

1.

A client had a 1000 mL bag of 5% dextrose in 0.9% sodium chloride hung at 3:00 p.m. The nurse making rounds at 3:45 p.m. finds that the client is complaining of a pounding headache and is dyspneic, experiencing chills and apprehensive, with an increasd pulse rate. The intravenous (IV) bag has 400 mL remaining. The nurse should take which of the following actions first?

1. Call the physician

2. Slow the IV infusion

3. Sit the client up in bed

4. Remove the IV catheter

To see the correct answer and rationale, click here!

2.

The burn client is receiving treatments of topical mafenide acetate (Sulfamylon) to the site of injury. The nurse monitors the client, knowing that which of the following indicates that a systemic effect has occurred?

1. Hyperventilation

2. Elevated blood pressure

3. Local pain at the burn site

4. Local rash at the burn site

To see the correct answer and rationale, click here!

 

3.

The nurse places highest priority on assessing for which of the following most common and most lethal side effects of chemotherapy using Bleomycin?

1. Increased respiratory rate

2. Electrolyte imbalance

3. Myelosuppression

4. Elevated liver function studies

To see the correct answer and rationale, click here

 

4.

The nurse assesses the client receiving gentamycin (Garamycin) for which two most specific toxicities?

1. Hepatotoxicity and neurotoxicity

2. Nephrotoxicity and ototoxicity

3. Leukocytosis and thrombocytopenia

4. Pseudomembranous colitis and crystalluria

To see the correct answer and rationale, click here

 

5.

Aminophylline is supplied in a 500mg/2.5mL solution. How much would be given if an order were written for 100mg aminophylline IV?

1. 5 mL

2. 1.5mL

3. 2.5 mL

4. 0.5 mL

To see the correct answer and rationale, click here

 

6.

Robitussin cough syrup 225 mg PO is ordered. The bottle reads: 600 mg in 1 ounce. How many mL of cough syrup will you give?

1. 11.25 mL

2. 30 mL

3. 1.5 mL

4. 12 ounces

To see the correct answer and rationale, click here

 

7.

Tylenol gr x is prescribed. Tylenol elixer is labeled 160 mg per teaspoon. Give _______mL

1. 10.5 mL

2. 15 mL

3. 18.75 mL

4. 6.25 mL

To see the correct answer and rationale, click here

 

8.

The client with a C-5 SCI is complaining of a pounding headache, "9" on a pain scale of 1-10. Which intervention should the rehabilitation nurse implement first?

1. Notify the health care provider

2. Elevate the head of the bed

3. Assess the bladder for distention

4. Take the client's blood pressure

To see the correct answer and rationale, click here

 

9.

The charge nurse on the busy 36-bed rehabilitation unit must send one staff member to the emergency depatment (ED). Which staff member would be the most appropriate person to send?

1.The LPN who has worked on the rehabiliation unit for 3 years

2. The RN who has been employed on the rehabilitation unit for 8 years

3. The UAP who is completing the 4-week orientation to the rehabilitation unit

4. The RN who transferred to the rehabilitation unit from the medical unit

To see the correct answer and rationale, click here

 

10.

The nurse in the rehabilitation unit is caring for clients along with a UAP. Which action by the UAP warrants immediate attention?

1. The UAP assistas a client 1 week postoperatively to eat a regular diet

2. The UAP calles for assistance when taking a client to the shower

3. The UAP is assisting the client who weighs 181 kg to the bedside commode

4. The UAP places the call light within reach of the client who is sitting in the chair

To see the correct answer and rationale, click here

 

11.

The nurse and the UAP are caring for residents in a long-term care facility. Which task should the nurse delegate to the UAP?

1. Apply a sterile dressing to a stage IV pressure wound

2. Check the blood glucose level of a resident who is weak and shaky

3. Document the amount of food the residents ate after a meal

4. Teach residents how to play different types of bingo

To see the correct answer and rationale, click here

 

12.

The elderly client diagnosed with deep vein thrombosis is complaining of chest pain during inhalation. Which intervention should the nurse implement first?

1. Ask the health care provider to order a stat lung scan

2. Placed oxygen on the client via nasal cannula

3. Prepare to administer intravenous heparin

4. Tell the client not to ambulate and to remain in bed

To see the correct answer and rationale, click here

 

 

 

 

 

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