NCLEX-RN Nursing — All Questions

The pharmacy sends vancomycin 1 g in 250 mL of dextrose 5% in water labelled to infuse over 30 minutes. Which action should the nurse take?

• a.Start the infusion as sent and draw a trough level 30 minutes afterward.
• b.Question the rate, since a dose is infused over at least 60 minutes.✓
• c.Infuse it by gravity and count the drip rate every 15 minutes.
• d.Premedicate with diphenhydramine and infuse the dose over 30 minutes.

Vancomycin labelling directs that each dose be given at no more than 10 mg/min or over a period of at least 60 minutes, because rapid infusion can cause exaggerated hypotension and flushing of the upper body. Premedicating does not make an unsafe rate safe, and a trough drawn immediately after the dose does not address the rate at all.

A client who had a mechanical mitral valve replacement is taking warfarin. Today's INR is 1.6. How should the nurse interpret this result?

• a.Below the target range of 2.5 to 3.5 for a mechanical mitral valve✓
• b.Within the target range of 1.5 to 2.0 for a mechanical mitral valve
• c.Within the target range of 1.6 to 2.5 for a mechanical mitral valve
• d.Above the target range of 1.0 to 1.5 for a mechanical mitral valve

Warfarin labelling sets a target INR of 3.0 with a range of 2.5 to 3.5 for a mechanical mitral valve, so an INR of 1.6 is subtherapeutic and leaves the client at risk for valve thrombosis. The lower ranges offered belong to no labelled warfarin indication; even venous thromboembolism and atrial fibrillation are anticoagulated to 2.0 to 3.0.

A client takes lithium carbonate at 0800 and at 2000. The provider orders a serum lithium level. When should the nurse arrange the blood draw?

• a.Just before the 0800 dose, 8 to 12 hours after the evening dose✓
• b.Just after the 2000 dose, at the end of the dosing day
• c.One hour after the 0800 dose, when absorption is complete
• d.At about 1400, roughly midway between the two scheduled doses

Lithium labelling directs that blood samples be drawn immediately prior to the next dose, 8 to 12 hours after the previous dose, when concentrations are relatively stable. A sample drawn soon after a dose reflects the absorption peak and can look falsely toxic, which may lead to an unnecessary dose reduction.

A client with heart failure takes lisinopril daily and has a new prescription for spironolactone. This morning's serum potassium is 5.9 mEq/L. Which action should the nurse take?

• a.Give both drugs and add an oral potassium supplement at noon.
• b.Hold the spironolactone and report the potassium result.✓
• c.Hold the lisinopril and give the spironolactone as prescribed.
• d.Give the spironolactone and recheck the potassium in 3 days.

Spironolactone is contraindicated in hyperkalemia, and its labelling warns that the risk rises when it is combined with an ACE inhibitor such as lisinopril; a potassium of 5.9 mEq/L is above the upper limit of normal, so the dose is held and reported. Substituting one of the two drugs for the other still adds a potassium-raising agent to an already elevated level.

A client with rheumatoid arthritis is going home on oral methotrexate. Which statement by the client indicates that the teaching about the regimen was effective?

• a.I take one tablet each morning with my breakfast.
• b.I take an extra dose on days my joints ache more.
• c.I have my blood counts checked once a year.
• d.I take the whole dose on one day each week.✓

Methotrexate for rheumatoid arthritis is prescribed once weekly, and the labelling states plainly that mistaken daily use of the recommended dose has led to fatal toxicity, so taking the full amount on a single day of the week shows the teaching took hold. Daily or extra dosing is the dangerous error the warning exists for, and blood counts are followed at least monthly during therapy rather than yearly.

A client with severe preeclampsia is receiving IV magnesium sulfate. The nurse finds the patellar reflex absent, respirations 10 breaths per minute, and urine output 20 mL over the past hour. Which action should the nurse take first?

• a.Stop the magnesium infusion and prepare to give calcium gluconate.✓
• b.Continue the infusion and recheck the patellar reflex in one hour.
• c.Give a 500 mL fluid bolus and recheck the urine output in 2 hours.
• d.Increase the magnesium rate and turn the client onto her left side.

Magnesium sulfate labelling names the presence of the patellar reflex, respirations of about 16 or more per minute, and urine output of 100 mL every 4 hours as indicators of a safe regimen, and directs that an injectable calcium salt be immediately available to counteract magnesium intoxication. Continuing or increasing the infusion while reflexes are gone risks respiratory paralysis.

A client who received naloxone for respiratory depression after a dose of extended-release morphine is now awake with a respiratory rate of 16. Which action should the nurse take?

• a.Restart the morphine infusion at half of the previous rate.
• b.Give the next morphine dose now that the client is awake.
• c.Document the recovery and resume routine shift assessments.
• d.Keep monitoring, since the morphine may outlast the naloxone.✓

Naloxone labelling warns that the duration of action of most opioids may exceed that of naloxone, so respiratory and central nervous system depression can return after an initial improvement and the client needs continued surveillance and possibly repeat doses. Returning to routine assessments or redosing the opioid treats the improvement as permanent.

A postoperative client who received IV midazolam and IV hydromorphone is difficult to arouse with a respiratory rate of 7. Flumazenil is prescribed. Which understanding should guide the nurse's care?

• a.It reverses the hydromorphone and leaves the midazolam fully active.
• b.It reverses both drugs, so no other reversal agent is needed.
• c.It will work only after the hydromorphone has been fully metabolized.
• d.It reverses the midazolam but has no effect on the hydromorphone.✓

Flumazenil labelling states that it reverses the sedative effects of benzodiazepines and does not reverse the effects of opioids, so opioid-related respiratory depression persists and naloxone may still be required. Labelling also directs monitoring for resedation for up to 120 minutes after flumazenil is given.

Fifteen minutes into a transfusion of packed red blood cells, a client has shaking chills, flank pain, dark red urine, and a temperature that has risen from 37.6 C to 39.1 C. Which action should the nurse take first?

• a.Change the infusing solution to lactated Ringer's and continue the unit slowly.
• b.Stop the transfusion and keep the vein open with 0.9% sodium chloride through new tubing.✓
• c.Give the prescribed antipyretic and continue the transfusion at the ordered rate.
• d.Slow the transfusion to 50 mL per hour and recheck the temperature and pulse in 15 minutes.

When a transfusion reaction occurs the transfusion must be discontinued immediately; fresh tubing and 0.9% sodium chloride preserve venous access without delivering any more of the implicated unit, and these findings suggest an acute hemolytic reaction. Lactated Ringer's contains calcium and should not be infused through the same tubing as a citrated blood component.

An 82-year-old client with chronic anemia and heart failure receives 2 units of packed red blood cells over 2 hours. One hour later the client has dyspnea, crackles, jugular venous distention, blood pressure 178/96 mm Hg, and oxygen saturation 87%. Which complication do these findings most suggest?

• a.Transfusion-associated circulatory overload✓
• b.Acute hemolytic transfusion reaction
• c.Febrile nonhemolytic transfusion reaction
• d.Transfusion-related acute lung injury

Circulatory overload follows volumes or rates the heart cannot accommodate and shows hydrostatic pulmonary edema with hypertension and jugular venous distention, and the elderly and clients with chronic anemia or cardiac disease are at particular risk. Transfusion-related acute lung injury also causes hypoxemia within 6 hours but produces noncardiogenic edema with hypotension rather than the volume-overload picture described.

A nurse is 10 minutes into a client's first intravenous dose of a cephalosporin antibiotic. Which finding requires immediate intervention?

• a.A blood pressure of 126/78 and a pulse of 94
• b.Hoarseness and wheezing with swollen lips✓
• c.A small bruise where the catheter was inserted
• d.A dull headache that began before the infusion

Mucosal swelling together with airway findings such as hoarseness and wheezing minutes after a drug exposure meets the clinical criteria for anaphylaxis, so the infusion is stopped and intramuscular epinephrine, 0.3 to 0.5 mL of the 1:1,000 concentration into the mid-outer thigh, is given without delay; antihistamines are adjuncts whose benefit in anaphylaxis is unproven and they do not protect the airway. The other findings are unremarkable vital signs, a local mark at the insertion site, and a symptom that started before the drug was hung.

A client's continuous parenteral nutrition bag empties and the replacement bag is delayed in the pharmacy. For which complication should the nurse assess this client?

• a.Hypernatremia with dry mucous membranes
• b.Hypercalcemia with severe muscle weakness
• c.Hyperkalemia with peaked T waves on the ECG
• d.Hypoglycemia with diaphoresis and tremor✓

Sudden discontinuation of parenteral nutrition can lead to hypoglycemia, because circulating insulin remains high after the concentrated dextrose infusion stops. The nurse checks a capillary glucose, watches for diaphoresis and tremor, and obtains the replacement solution without delay.

A nurse enters the room of a client using an intravenous patient-controlled analgesia pump and finds the client's daughter pressing the demand button while the client sleeps. Which action should the nurse take?

• a.Stop the daughter and teach that only the client presses the button.✓
• b.Tell the daughter to press it once an hour through the overnight shift.
• c.Thank the daughter for helping the client stay ahead of the pain overnight.
• d.Ask the daughter to press it only when the client moans in pain.

Dosing by anyone other than the client removes the built-in safeguard that a sedated client cannot press the button, and this practice has been documented to cause respiratory depression. Teaching the family before and during therapy that only the client presses the button is the intervention; setting a schedule for the daughter keeps the hazard in place.