NCLEX-PN Test #3 2

Question 1

A client with heart failure is prescribed furosemide 40 mg IV. Which electrolyte must the nurse monitor most closely?

Accepted Answer

Potassium

Answer

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?

Accepted Answer

Nasal cannula at 1–2 L/min

Answer

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?

Accepted Answer

Troponin I

Answer

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?

Accepted Answer

Unilateral calf pain, warmth, and swelling

Answer

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?

Accepted Answer

Administer anticoagulation therapy as ordered

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #3 2