NCLEX-PN Test #5 2

Question 1

A client is prescribed morphine sulfate 4 mg IV every 4 hours PRN for pain. The medication on hand is morphine 10 mg/mL. How many mL should the nurse administer?

Accepted Answer

0.4 mL

Answer

Using the formula: Dose desired ÷ Dose on hand × Volume = 4 mg ÷ 10 mg × 1 mL = 0.4 mL. This is a critical calculation — administering the wrong volume of a concentrated opioid can cause respiratory depression and death.

Question 2

A client is taking warfarin (Coumadin) for atrial fibrillation. Which dietary instruction is most important?

Accepted Answer

Maintain a consistent intake of vitamin K-rich foods

Answer

Warfarin's anticoagulant effect is inversely related to vitamin K intake. Clients do NOT need to eliminate vitamin K foods but must keep intake consistent. Dramatic changes in vitamin K intake cause INR fluctuations and bleeding risk or subtherapeutic anticoagulation. Complete avoidance is unnecessary and can be harmful.

Question 3

A client is prescribed phenytoin (Dilantin) for seizure management. Which side effect is a sign of toxicity and requires immediate action?

Accepted Answer

Nystagmus and ataxia

Answer

Nystagmus (involuntary eye movement) and ataxia (loss of coordination) are signs of phenytoin toxicity (therapeutic range 10–20 mcg/mL). They indicate serum levels are too high. Gingival hyperplasia and drowsiness are common side effects, not toxicity. A severe skin rash may indicate Stevens-Johnson syndrome and also requires immediate action.

Question 4

Which "five rights" of medication administration is the nurse checking when scanning the client's armband and medication barcode?

Accepted Answer

Right client and right medication

Answer

Barcode medication administration (BCMA) systems verify the right client (by matching the armband ID) and the right medication (by scanning the drug barcode). The nurse is responsible for all five rights, but BCMA technology specifically addresses client identification and medication verification.

Question 5

A client with type 2 diabetes is started on glipizide (a sulfonylurea). What is the most important safety teaching?

Accepted Answer

Monitor for hypoglycemia, especially if meals are delayed or skipped

Answer

Sulfonylureas stimulate the pancreas to release insulin regardless of blood glucose level, making hypoglycemia a significant risk — especially if a meal is delayed, skipped, or inadequate. Clients must be taught to recognize and treat hypoglycemia (glucose tablets, juice) and eat consistently.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #5 2