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

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?

Accepted Answer

Hold metformin before the scan and notify the provider

Answer

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?

Accepted Answer

Stop the infusion and notify the provider

Answer

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?

Accepted Answer

Document the symptom and schedule an appointment with the provider

Answer

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?

Accepted Answer

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

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #2 1