NCLEX-PN Test #3 2 — Questions and Answers
Question 1: A client with heart failure is prescribed furosemide 40 mg IV. Which electrolyte must the nurse monitor most closely?
- Sodium
- Calcium
- Potassium (Correct answer)
- Magnesium
Correct answer: Potassium
Furosemide is a loop diuretic that causes significant potassium loss in the urine (hypokalemia). Hypokalemia increases the risk of life-threatening cardiac dysrhythmias, especially in clients also taking digoxin. Serum potassium must be monitored before and after administration.
Question 2: A client with COPD has an O₂ saturation of 88% on room air. The PN prepares to administer supplemental oxygen. What is the appropriate initial oxygen delivery method and flow rate?
- Non-rebreather mask at 15 L/min
- Simple face mask at 8 L/min
- Nasal cannula at 1–2 L/min (Correct answer)
- Venturi mask at 40% FiO₂
Correct answer: Nasal cannula at 1–2 L/min
Clients with COPD rely on hypoxic drive to breathe. High-flow oxygen can suppress their respiratory drive. The standard initial approach is low-flow oxygen via nasal cannula at 1–2 L/min, titrating to maintain SpO₂ at 88–92%. High-flow methods risk respiratory depression.
Question 3: A client is admitted with a suspected myocardial infarction. Which laboratory value is the most specific indicator of myocardial damage?
- AST (aspartate aminotransferase)
- CK-MB (creatine kinase myocardial band)
- Troponin I (Correct answer)
- LDH (lactate dehydrogenase)
Correct answer: Troponin I
Troponin I is the most cardiac-specific biomarker. It rises within 3–6 hours of myocardial injury, peaks at 12–24 hours, and remains elevated for 7–10 days. It has greater specificity for myocardial damage than CK-MB, which can also rise with skeletal muscle injury.
Question 4: The PN is assessing a client with deep vein thrombosis (DVT). Which assessment finding is most consistent with this diagnosis?
- Bilateral leg edema that is worse in the morning
- Unilateral calf pain, warmth, and swelling (Correct answer)
- Intermittent claudication relieved by rest
- Pallor and pulselessness in one extremity
Correct answer: Unilateral calf pain, warmth, and swelling
DVT typically presents with unilateral findings: calf pain, warmth, erythema, and edema due to venous obstruction and inflammation. Bilateral morning edema suggests systemic causes (heart failure, renal disease). Intermittent claudication and pulselessness indicate arterial, not venous, disease.
Question 5: A client is admitted for pulmonary embolism. Which nursing intervention is the priority?
- Administer anticoagulation therapy as ordered (Correct answer)
- Apply compression stockings
- Encourage ambulation to prevent further clots
- Obtain a 12-lead ECG
Correct answer: Administer anticoagulation therapy as ordered
The priority treatment for pulmonary embolism is anticoagulation (typically IV heparin) to prevent further clot extension and new clot formation. This is an emergency. While compression stockings and monitoring are important adjuncts, anticoagulation is the immediate priority intervention.
Question 6: A client with hypertension is prescribed atenolol (a beta-blocker). What should the nurse teach regarding signs of toxicity?
- Tachycardia and palpitations
- Bradycardia and heart block (Correct answer)
- Severe headache and visual changes
- Dry cough and angioedema
Correct answer: Bradycardia and heart block
Beta-blockers suppress heart rate and atrioventricular conduction. Toxicity manifests as bradycardia, heart block, hypotension, and bronchospasm. Clients should be taught to monitor pulse before each dose and hold the medication if heart rate falls below 60 bpm.
NCLEX-PN Test #3 2
A client with heart failure is prescribed furosemide 40 mg IV.
Which electrolyte must the nurse monitor most closely?