Department of Nursing > Learning Enhancement Center

Department of Nursing
PO Box 1510
Pembroke, NC 28372

Phone: 910.521.6522
Fax: 910.521.6178
Email: nursing@uncp.edu

Location: Nursing Building
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nclex-rn question of the week answers and rationales

If you selected (2) as the correct answer, congratulations! You are correct. As indicated by Silvestri (2009) the symptoms experienced by this client are indicative of fluid overload. You should have noted that the client has had 600mL of fluid to infuse in only 45 minutes! While the other actions will be carried out in sequnce, the question asked what you would do FIRST. Raising the head of the bed will help the client to breath easier if necessary and you should notify the physician immediately. Removing the IV catheter is not necessary.

This is an application question that deals with the client's physiological integrity and the implementation phase of the nursing process.

Silvestri, L.A. (2009). Comprehensive review for the NCLEX-RN examination (4th ed.). St. Louis: Saunders.

If you selected (1) as the correct answer, way to go. Sulfamylon (mafenide acetate) is a carbonic anhydrase inhibitor and can suppress renal excretion of acid causing acidosis. So, you should monitor this client for signs and symptoms of an acid-base imbalance (hyperventilation).

This is an analysis question which deals with the client's physiological integrity and the assessment phase of the nursing process.

Silvestri, L.A. (2009). Comprehensive review for the NCLEX-RN examination (4th ed.). St. Louis: Saunders.

If you selected (1) you are correct! Pulmonary toxicity is a common side effect of Bleomycin. Think "blue for bleomycin" to make sure you remember its respiratory effects.

This is an analysis question dealing with assessment phase of the nursing process.

Hogan, M.A. (2005). Pharmacology: Reviews and rationales. Upper Saddle River, NJ: Prentice Hall.

If you selected (2) you are correct. Remember that the most common adverse effects of aminoglycosides are nephrotoxicity and ototoxicity.

This is an application question dealing with the assessment phase of the nursing process.

Hogan, M.A. (2005). Pharmacology: Reviews and rationales. Upper Saddle River, NJ: Prentice Hall.

If you selected (4) you are correct. Once you have calculated your answer, always ask yourself if it makes sense. Does the dose seem too large or too small. Always double check your work.

Karch, A.M. (2008). Focus on nursing pharmacology (4th ed.). Philadelphia: Lippincott, Williams & Wilkins.

Did you select (1)? If so, you are correct. Did you remember that you were being asked for mL and not ounces? If so, you knew that 1 ounce = 30 mL. Therefore, 11.25 mL was the correct answer. Good job.

Karch, A.M. (2008). Focus on nursing pharmacology (4th ed.). Philadelphia: Lippincott, Williams & Wilkins.

Did you select 18.75 mL. If so, you are correct. Remember that 1 grain = 60 mg so 10 grains = 600 mg (60 x 10). If you had been asked how many teaspoons to give, what would your answer be?

8: Did you select "Take the cilent's blood pressure?" If so, you are correct. It isn't "1" because you assess first, then intervene. It isn't "2" because while this may help to lower the BP, you don't know if the BP is actually high, right? It isn't "3" because if the BP is elevated it is most likely due to autonomic dysreflexia (an acute emergency) that is associated with clients with SCI above T-6.