NCLEX-PN Test #10 3 — Questions and Answers
Question 1: A client is prescribed digoxin 0.25 mg PO daily. Before administering, the nurse checks the apical pulse and finds it to be 54 bpm. What action should the nurse take?
- Administer the digoxin as ordered — this is within normal range
- Hold the digoxin and notify the provider (Correct answer)
- Administer half the dose and monitor closely
- Give the dose and recheck pulse in 30 minutes
Correct answer: Hold the digoxin and notify the provider
Digoxin slows the heart rate (negative chronotropy) and increases contractility. The standard protocol is to hold digoxin and notify the provider if the apical pulse is below 60 bpm in adults (or below established parameters) to prevent further bradycardia and potential cardiac arrest from digoxin toxicity.
Question 2: A client is receiving IV vancomycin. During the infusion, the client develops flushing, erythema, and pruritus of the face, neck, and upper torso. What action should the nurse take first?
- Stop the infusion and administer epinephrine for anaphylaxis
- Slow the infusion rate — this is Red Man Syndrome, not an allergic reaction (Correct answer)
- Stop the infusion, administer diphenhydramine, and document as a true allergy
- Increase the infusion rate to rapidly complete the dose
Correct answer: Slow the infusion rate — this is Red Man Syndrome, not an allergic reaction
Red Man Syndrome is a rate-related (not immune-mediated) reaction to vancomycin caused by direct mast cell degranulation. It presents with flushing, erythema, and pruritus of the face/neck/upper body. Management is to slow or stop the infusion and administer diphenhydramine. It is not a true allergy. Vancomycin should infuse over at least 60 minutes per gram.
Question 3: The "seven rights" of medication administration include the five traditional rights plus which two additional rights?
- Right temperature and right expiration date
- Right reason and right response (evaluation) (Correct answer)
- Right storage and right preparation
- Right frequency and right duration
Correct answer: Right reason and right response (evaluation)
The expanded seven rights of medication administration add: (6) Right reason — confirm the clinical indication for the medication, and (7) Right response (documentation/evaluation) — assess and document the client's response to the medication. These additions promote clinical thinking beyond the mechanics of delivery.
Question 4: A nurse is preparing to administer a scheduled dose of enoxaparin (Lovenox) subcutaneously. Which action is correct?
- Aspirate before injecting to ensure correct placement
- Expel the air bubble from the prefilled syringe before injection
- Inject into the abdomen, 2 inches from the navel, and do not rub the site after injection (Correct answer)
- Massage the injection site vigorously for 30 seconds after administration
Correct answer: Inject into the abdomen, 2 inches from the navel, and do not rub the site after injection
For enoxaparin (LMWH) subcutaneous injection: select the anterolateral or posterolateral abdominal wall at least 2 inches from the navel, do NOT aspirate (can cause tissue trauma/hematoma), do NOT rub the site after injection (increases bruising), and do NOT expel the air bubble (it ensures the full dose is delivered). Rotate sites.
Question 5: The PN receives a verbal order from a physician over the phone for a new medication. What is the correct procedure?
- Write the order and implement it immediately
- Repeat the order back to the provider (read-back), document as a verbal order, and have the provider co-sign within the required timeframe (Correct answer)
- Refuse all verbal orders and ask the provider to enter orders electronically
- Implement the order and ask a colleague to verify it
Correct answer: Repeat the order back to the provider (read-back), document as a verbal order, and have the provider co-sign within the required timeframe
Telephone and verbal orders require the read-back (echo-back) technique: write down the order, then read it back to the prescriber for confirmation. Document as a verbal/telephone order with the time, date, provider name, and nurse signature. The prescriber must co-sign within the institution's required timeframe (usually 24–48 hours).
Question 6: A client is prescribed IV potassium chloride 20 mEq in 100 mL NS to infuse over 1 hour. The nurse notes this is a concentrated potassium preparation. What is the most critical safety check before administration?
- Confirm the order is for IV push administration
- Verify the infusion rate — potassium must never exceed 10–20 mEq/hour IV and must be given diluted, never IV push (Correct answer)
- Ensure the client is NPO before potassium infusion
- Check that the IV site is in the subclavian vein only
Correct answer: Verify the infusion rate — potassium must never exceed 10–20 mEq/hour IV and must be given diluted, never IV push
Potassium chloride is a high-alert medication. IV potassium must NEVER be given as an IV push (causes fatal cardiac arrest). It must always be diluted and infused at ≤10–20 mEq/hour. Concentrated potassium solutions must be flagged, and infusion rates verified by two nurses per policy. Cardiac monitoring is recommended for rates > 10 mEq/hr.
NCLEX-PN Test #10 3
A client is prescribed digoxin 0.25 mg PO daily.
Before administering, the nurse checks the apical pulse and finds it to be 54 bpm.
What action should the nurse take?