NCLEX-PN Test #2 1 — Questions and Answers
Question 1: A nurse is preparing to administer digoxin 0.125 mg PO to a client with heart failure. Before giving the dose, the nurse assesses the apical pulse and finds it is 54 beats/min. Which action should the nurse take?
- Administer the dose and document the pulse rate
- Hold the dose and notify the provider (Correct answer)
- Administer half the prescribed dose
- Give the dose and reassess in 30 minutes
Correct answer: Hold the dose and notify the provider
Digoxin should be held and the provider notified when the apical pulse is below 60 beats/min in an adult. Bradycardia is a sign of digoxin toxicity and administering the dose could worsen the condition.
Question 2: A client is prescribed metformin 500 mg PO twice daily for type 2 diabetes. The client is scheduled for a contrast CT scan tomorrow. Which nursing action is most appropriate?
- Administer metformin as prescribed until the scan
- Hold metformin before the scan and notify the provider (Correct answer)
- Double the dose the day before to compensate
- Switch the client to insulin without consulting the provider
Correct answer: Hold metformin before the scan and notify the provider
Metformin must be held before contrast dye procedures because the combination can cause lactic acidosis and acute kidney injury. The provider must be notified to clarify when to resume the medication after adequate renal function is confirmed.
Question 3: A nurse is administering IV vancomycin to a client when the client suddenly develops flushing, erythema, and hypotension along the neck and upper torso. Which intervention should the nurse perform first?
- Administer diphenhydramine IV as ordered
- Stop the infusion and notify the provider (Correct answer)
- Increase the IV fluid rate to treat hypotension
- Slow the infusion rate and continue monitoring
Correct answer: Stop the infusion and notify the provider
The client is experiencing Red Man Syndrome, an infusion-related reaction to vancomycin. The priority action is to stop the infusion immediately and notify the provider. Slowing the rate may be an eventual intervention, but stopping and notifying comes first.
Question 4: A client with hypertension is taking lisinopril. The client calls the clinic reporting a persistent dry cough for the past two weeks. Which response by the nurse is most appropriate?
- Tell the client this is a normal side effect that will resolve on its own
- Advise the client to take the lisinopril with food to reduce coughing
- Document the symptom and schedule an appointment with the provider (Correct answer)
- Instruct the client to stop the medication immediately
Correct answer: Document the symptom and schedule an appointment with the provider
A persistent dry cough is a common adverse effect of ACE inhibitors like lisinopril caused by bradykinin accumulation. The nurse should document and schedule a provider visit, as the medication may need to be changed to an ARB. The nurse should not advise the client to stop the medication without a provider order.
Question 5: A nurse is preparing to administer morphine sulfate 4 mg IV to a postoperative client for pain. The client's respiratory rate is 10 breaths/min. Which action should the nurse take?
- Administer the dose and monitor closely
- Hold the dose and assess pain level first
- Hold the dose, notify the provider, and have naloxone available (Correct answer)
- Administer half the dose and reassess in 15 minutes
Correct answer: Hold the dose, notify the provider, and have naloxone available
A respiratory rate of 10 breaths/min indicates respiratory depression, a serious opioid side effect. The nurse must hold the morphine, notify the provider, and have naloxone (the opioid antagonist) available for potential reversal. Administering any amount of opioid with respiratory depression present is unsafe.
Question 6: A client is receiving warfarin therapy for atrial fibrillation. The INR result returns at 4.8. The client has no signs of bleeding. Which intervention should the nurse anticipate?
- Continue the current warfarin dose and recheck the INR in one week
- Administer vitamin K and hold the next warfarin dose as ordered (Correct answer)
- Give protamine sulfate to reverse anticoagulation
- Increase the warfarin dose to stabilize the INR
Correct answer: Administer vitamin K and hold the next warfarin dose as ordered
An INR of 4.8 is supratherapeutic (therapeutic range for atrial fibrillation is 2.0–3.0). With no active bleeding, the expected interventions are holding the warfarin dose and possibly giving vitamin K as ordered. Protamine sulfate reverses heparin, not warfarin. Increasing the dose would be dangerous.
NCLEX-PN Test #2 1
A nurse is preparing to administer digoxin 0.125 mg PO to a client with heart failure.
Before giving the dose, the nurse assesses the apical pulse and finds it is 54 beats/min.
Which action should the nurse take?