NCLEX-PN Test #2 1

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?

Accepted Answer

Hold the dose and notify the provider

Answer

Administer the dose and document the pulse rate

Answer

Administer half the prescribed dose

Answer

Give the dose and reassess in 30 minutes

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?

Accepted Answer

Hold metformin before the scan and notify the provider

Answer

Administer metformin as prescribed until the scan

Answer

Double the dose the day before to compensate

Answer

Switch the client to insulin without consulting the provider

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?

Accepted Answer

Stop the infusion and notify the provider

Answer

Administer diphenhydramine IV as ordered

Answer

Increase the IV fluid rate to treat hypotension

Answer

Slow the infusion rate and continue monitoring

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?

Accepted Answer

Document the symptom and schedule an appointment with the provider

Answer

Tell the client this is a normal side effect that will resolve on its own

Answer

Advise the client to take the lisinopril with food to reduce coughing

Answer

Instruct the client to stop the medication immediately

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?

Accepted Answer

Hold the dose, notify the provider, and have naloxone available

Answer

Administer the dose and monitor closely

Answer

Hold the dose and assess pain level first

Answer

Administer half the dose and reassess in 15 minutes

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?

Accepted Answer

Administer vitamin K and hold the next warfarin dose as ordered

Answer

Continue the current warfarin dose and recheck the INR in one week

Answer

Give protamine sulfate to reverse anticoagulation

Answer

Increase the warfarin dose to stabilize the INR