NCLEX - National Council Licensure Examination Test #24 1 — Questions and Answers
Question 1: A nurse is preparing to administer digoxin to a client with heart failure. Which assessment finding should prompt the nurse to withhold the medication and notify the provider?
- Apical pulse of 72 beats per minute
- Apical pulse of 54 beats per minute (Correct answer)
- Blood pressure of 138/86 mmHg
- Respiratory rate of 18 breaths per minute
Correct answer: Apical pulse of 54 beats per minute
Digoxin should be withheld if the apical pulse is below 60 bpm in adults before administration. Bradycardia can indicate digoxin toxicity or heightened sensitivity, and the provider must be notified before continuing therapy.
Question 2: A nurse is caring for a postpartum client 2 hours after vaginal delivery. Assessment reveals a boggy uterus displaced to the right of the midline. Which action should the nurse take first?
- Administer oxytocin as prescribed
- Notify the healthcare provider
- Assist the client to urinate (Correct answer)
- Massage the uterine fundus vigorously
Correct answer: Assist the client to urinate
A boggy uterus displaced to the right of the midline most commonly indicates a full bladder preventing uterine contraction and involution. Assisting the client to void is the priority first action before fundal massage or medications.
Question 3: A nurse is monitoring a client who has been taking lithium carbonate for bipolar disorder. Which serum lithium level indicates toxicity requiring immediate intervention?
- 0.7 mEq/L
- 1.0 mEq/L
- 1.4 mEq/L
- 2.2 mEq/L (Correct answer)
Correct answer: 2.2 mEq/L
The therapeutic range for lithium is 0.6–1.2 mEq/L (up to 1.5 mEq/L during acute mania). A level of 2.2 mEq/L falls well above this range and indicates toxicity, which can cause tremors, confusion, seizures, and cardiac dysrhythmias.
Question 4: A nurse is assessing a client 12 hours after a thyroidectomy. Which finding requires immediate intervention?
- Mild incisional discomfort rated 3/10
- Slight hoarseness of voice
- Positive Chvostek's sign (Correct answer)
- Serum calcium level of 8.6 mg/dL
Correct answer: Positive Chvostek's sign
A positive Chvostek's sign (facial twitching when the cheek is tapped) indicates hypocalcemia, which can occur after thyroidectomy due to inadvertent removal or damage to the parathyroid glands. Severe hypocalcemia can lead to tetany and laryngospasm and requires immediate treatment.
Question 5: A nurse is caring for a client with chronic kidney disease (CKD) stage 4. Which dietary instruction is most appropriate?
- Eat bananas and oranges daily for vitamins
- Increase protein intake to support healing
- Limit foods high in potassium and phosphorus (Correct answer)
- Drink at least 3 liters of fluid per day
Correct answer: Limit foods high in potassium and phosphorus
In CKD, impaired kidneys cannot adequately excrete potassium and phosphorus, leading to hyperkalemia and hyperphosphatemia, which cause cardiac and bone complications. Restricting these electrolytes is essential to managing the disease.
Question 6: A client receiving a blood transfusion develops fever, chills, and severe lower back pain 20 minutes into the infusion. Which action should the nurse take first?
- Slow the transfusion rate to 25 mL/hr
- Administer diphenhydramine as prescribed
- Stop the transfusion immediately (Correct answer)
- Collect a urine specimen for hemoglobinuria
Correct answer: Stop the transfusion immediately
Fever, chills, and back pain during a transfusion are hallmark signs of an acute hemolytic transfusion reaction, which is life-threatening due to ABO incompatibility. Stopping the transfusion immediately is the priority to prevent further hemolysis and potential renal failure.
NCLEX - National Council Licensure Examination Test #24 1
A nurse is preparing to administer digoxin to a client with heart failure.
Which assessment finding should prompt the nurse to withhold the medication and notify the provider?