NCLEX style questions - FTZ

A health care provider orders 0.5 mg of protamine sulfate for a client who is showing signs of bleeding after receiving a 100-unit dose of heparin. The nurse should expect the effects of the protamine sulfate to be noted in which of the following time frames? *. 5 minutes. *. 10 minutes. *. 20 minutes. *. 30 minutes

*. 20 minutes Reason: A dose of 0.5 mg of protamine sulfate reverses a 100-unit dose of heparin within 20 minutes. The nurse should administer protamine sulfate by I.V. push slowly to avoid adverse effects, such as hypotension, dyspnea, bradycardia, and anaphylaxis

The nurse is assessing a client's testes. Which of the following findings indicate the testes are normal? *. Soft. *. Egg-shaped. *. Spongy. *. Lumpy.

*. Egg-shaped. Reason: Normal testes feel smooth, egg-shaped, and firm to the touch, without lumps. The surface should feel smooth and rubbery. The testes should not be soft or spongy to the touch. Testicular malignancies are usually nontender, nonpainful hard lumps. Lumps, swelling, nodules, or signs of inflammation should be reported to the physician.

The nurse administers an intradermal injection to a client. Proper technique has been used if the injection site demonstrates which of the following? *. Minimal leaking. *. No swelling. *. Tissue pallor. *. Evidence of a bleb or wheal.

*. Evidence of a bleb or wheal. Reason: A properly administered intradermal injection shows evidence of a bleb or wheal at the injection site. There should be no leaking of medication from the bleb; it needs to be absorbed into the tissue. Lack of swelling at the injection site means that the injection was given too deeply. The presence of tissue pallor does not indicate that the injection was given correctly

a patient is taking digoxin. which sign exhibited by the patient would most clearly indicate that the digoxin could be given safely? *. HR of 80bpm *. lung sounds are clear *. oriented to person, place and time *. tolerating diet well

*. HR of 80bpm

An Arab client with pneumonia has been admitted to the health care facility. What should the nurse avoid while conducting the interview of the client? *. Giving a light handshake. *. Maintaining eye contact. *. Asking about the client's symptoms. *. Asking about the client's medical history.

*. Maintaining eye contact. Reason: While interviewing an Arab client, the nurse should avoid maintaining eye contact. In Arab culture, maintaining eye contact is sexually suggestive; if the nurse does so during the interview, it may give the wrong message to the client. However, the nurse may give a light handshake or ask about the client's personal life and medical history during the interview.

in evaluating the effectiveness of warfarin (coumadin) which lab result should you monitor? *. electrolytes *. blucose *. CBC *. PT/PTT INR

*. PT/PTT INR

a patient asks the nurse to define a hypersensitivity reaction. the nurse begins by telling the patient that a hypersensitivity reaction is also called: *. synergistic reaction *. antagonistic reaction *. drug idiosyncrasy *. allergic reaction

*. allergic reaction

in monitoring drug therapy, the nurse is aware that a synergistic drug effect may be defined as: *. an effect greater than the sum of the separate actions of two or more drugs. *. an increase in the action of one of the two drugs given *. a neutralizing drug effect *. a comprehensive drug effect

*. an effect greater than the sum of the separate actions of two or more drugs

mr. carter has a rash and pruritus. you suspect an allergic reaction and immediately assess him for other more serious symptoms. what question would be the most important to ask? *. are you having difficulty breathing? *. have you noticed any blood in your stool? *. do you have a headache? *. are you having difficulty with your vision?

*. are you having difficulty breathing?

when a patient is discharged from the hospital on prolonged steroid therapy, it is most important for the nurse to instruct the client to: *. call the physician of questions arise *. return for a follow up appointment *. take medication with food *. do not stop therapy abruptly

*. do not stop therapy abruptly

a newly admitted patient has a history of liver disease. in planning the patients care, the nurse must consider that liver disease may result in a(n): *. increase in the excretion of a drug *. impaired ability to metabolize or detoxify the drug *. need to increase the dosage of a drug *. decrease in the rate of drug absorption

*. impaired ability to metabolize or detoxify the drug

a patient is to be started on antibiotic therapy. which of the following actions is the first priority: *. inform patient on type of therapy *. instruct patient how to take the medication at home *. obtain culture before starting antibiotic *. teach client about potential side effects of the medication

*. obtain culture before starting antibiotic

when evaluating the effectiveness of meperidine hydrochloride (demerol), the nurse would assess the patients: *. breath sounds *. bowel sounds *. orientation level *. pain level

*. pain level

A health care provider orders 0.5 mg of protamine sulfate for a client who is showing signs of bleeding after receiving a 100-unit dose of heparin. The nurse should expect the effects of the protamine sulfate to be noted in which of the following time frames? a) 5 minutes. b) 10 minutes. c) 20 minutes. d) 30 minutes.

20 minutes. Reason: A dose of 0.5 mg of protamine sulfate reverses a 100-unit dose of heparin within 20 minutes. The nurse should administer protamine sulfate by I.V. push slowly to avoid adverse effects, such as hypotension, dyspnea, bradycardia, and anaphylaxis.

A nurse is assessing a client's pulse. Which pulse feature should the nurse document? a) Timing in the cycle b) Amplitude c) Pitch d) Intensity

Amplitude Reason: The nurse should document the rate, rhythm, and amplitude, such as weak or bounding, of a client's pulse. Pitch, timing, and intensity aren't associated with pulse assessment.

Before preparing a client for surgery, the nurse assists in developing a teaching plan. What is the primary purpose of preoperative teaching? a) To determine whether the client is psychologically ready for surgery b) To express concerns to the client about the surgery c) To reduce the risk of postoperative complications d) To explain the risks associated with the surgery and obtain informed consent

To reduce the risk of postoperative complications Reason: Preoperative teaching helps reduce the risk of postoperative complications by telling the client what to expect and providing a chance for him to practice, before surgery, any required postoperative activities, such as breathing and leg exercises. The physician — not the nurse — is responsible for determining the client's psychological readiness for surgery. It's inappropriate for the nurse to express personal concerns about surgery to a client. The physician should describe alternative treatments and explain the risks to the client when obtaining informed consent.

Following a small-bowel resection, a client develops fever and anemia. The surface surrounding the surgical wound is warm to the touch and necrotizing fasciitis is suspected. Another manifestation that suggests necrotizing fasciitis is: *. erythema. *. leukocytosis. *. pressurelike pain. *. swelling.

pressurelike pain. Reason: Severe pressurelike pain out of proportion to visible signs distinguishes necrotizing fasciitis from cellulitis. Erythema, leukocytosis, and swelling are present in both cellulitis and necrotizing fasciitis