NCLEX-PN Test #2 2 — Questions and Answers
Question 1: A PN is caring for a client receiving IV heparin. Which laboratory value requires immediate notification of the charge nurse?
- aPTT 85 seconds (therapeutic range 60–100 s)
- Platelet count of 40,000/mm³ (Correct answer)
- Serum potassium 3.8 mEq/L
- INR of 1.1
Correct answer: Platelet count of 40,000/mm³
Heparin-induced thrombocytopenia (HIT) is a life-threatening complication. A platelet count of 40,000/mm³ is critically low and must be reported immediately. The aPTT value shown is within therapeutic range and does not require urgent notification.
Question 2: A postpartum client is 12 hours after vaginal delivery. The nurse assesses the fundus to be firm, two finger-breadths above the umbilicus, and deviated to the right. What is the priority nursing action?
- Document as a normal finding
- Administer oxytocin per protocol
- Ask the client to void (Correct answer)
- Increase IV fluid rate
Correct answer: Ask the client to void
A deviated uterine fundus is most commonly caused by a full bladder displacing the uterus. The priority action is to have the client void; if the bladder is emptied and the fundus repositions at or below the umbilicus midline, no further intervention is needed.
Question 3: The PN is preparing to administer a subcutaneous insulin injection to a diabetic client. Which site provides the most consistent insulin absorption?
- Outer upper arm
- Anterior thigh
- Abdomen (at least 2 inches from the navel) (Correct answer)
- Dorsal gluteal area
Correct answer: Abdomen (at least 2 inches from the navel)
The abdomen provides the fastest and most consistent absorption rate for subcutaneous insulin. Rotation within the abdominal site is recommended. The outer arm and thigh have slower, more variable absorption rates.
Question 4: A client at 36 weeks gestation reports decreased fetal movement. The nurse performs a non-stress test (NST). Which result indicates a reactive (normal) NST?
- Two accelerations of ≥15 bpm lasting ≥15 seconds within 20 minutes (Correct answer)
- One acceleration of ≥10 bpm lasting ≥10 seconds within 40 minutes
- Absence of late decelerations with three contractions
- Variable decelerations with fetal movement
Correct answer: Two accelerations of ≥15 bpm lasting ≥15 seconds within 20 minutes
A reactive NST requires at least two fetal heart rate accelerations of ≥15 bpm above baseline, each lasting at least 15 seconds, within a 20-minute window. This indicates fetal well-being and an intact autonomic nervous system.
Question 5: The PN is caring for a newborn at 2 hours of life. Which finding requires immediate intervention?
- Respiratory rate of 48 breaths per minute
- Axillary temperature of 36.1°C (97°F)
- Nasal flaring with intercostal retractions (Correct answer)
- Acrocyanosis of hands and feet
Correct answer: Nasal flaring with intercostal retractions
Nasal flaring with intercostal retractions are signs of respiratory distress in a newborn and require immediate intervention. Acrocyanosis (blue hands/feet) in the first hours is normal. A respiratory rate of 48/min is within the normal newborn range (30–60/min).
Question 6: A client is prescribed metronidazole (Flagyl) for a vaginal infection. What is the most important teaching point?
- Take the medication on an empty stomach
- Avoid dairy products during treatment
- Do not consume alcohol during treatment and for 48 hours after (Correct answer)
- Sunscreen is required due to photosensitivity
Correct answer: Do not consume alcohol during treatment and for 48 hours after
Metronidazole inhibits aldehyde dehydrogenase, causing a disulfiram-like reaction when alcohol is consumed. Clients must avoid all alcohol during treatment and for at least 48 hours after the last dose to prevent severe nausea, vomiting, flushing, and tachycardia.
NCLEX-PN Test #2 2
A PN is caring for a client receiving IV heparin.
Which laboratory value requires immediate notification of the charge nurse?