RN NCLEX-RN 4 — Questions and Answers
Question 1: A nurse is planning care for a client with major depression who is started on fluoxetine (Prozac). Which statement about antidepressant therapy is most important to include in discharge teaching?
- You will feel better within 24 to 48 hours of starting the medication.
- Therapeutic effects may take 2 to 4 weeks to appear. (Correct answer)
- You should stop the medication once you feel better.
- Avoid all physical activity while taking this medication.
Correct answer: Therapeutic effects may take 2 to 4 weeks to appear.
SSRIs typically require 2–4 weeks to produce full therapeutic effects; clients must be informed to continue the medication and not expect immediate results.
Question 2: A nurse is caring for a client with a nasogastric (NG) tube. Before administering a tube feeding, which action confirms proper tube placement?
- Auscultate for air insufflation over the epigastrium
- Aspirate gastric contents and check pH (Correct answer)
- Ask the client if they feel the tube in their stomach
- Flush the tube with 30 mL of water
Correct answer: Aspirate gastric contents and check pH
Aspirating contents and verifying a pH of ≤5.5 is the most reliable bedside method to confirm gastric versus pulmonary tube placement.
Question 3: A nurse is reviewing laboratory values for a client on digoxin therapy. Which finding should prompt the nurse to hold the medication and contact the provider?
- Serum digoxin level of 1.0 ng/mL
- Serum potassium of 3.0 mEq/L (Correct answer)
- Heart rate of 68 beats/min
- BUN of 18 mg/dL
Correct answer: Serum potassium of 3.0 mEq/L
Hypokalemia potentiates digoxin toxicity by competing for the same myocardial binding sites; a potassium of 3.0 mEq/L significantly increases the risk of fatal arrhythmias.
Question 4: A nurse is assessing a client with a suspected stroke. Which assessment tool helps identify stroke symptoms and guides the decision to activate the stroke response team?
- Glasgow Coma Scale (GCS)
- Cincinnati Prehospital Stroke Scale (CPSS) (Correct answer)
- NIH Stroke Scale (NIHSS)
- CAGE questionnaire
Correct answer: Cincinnati Prehospital Stroke Scale (CPSS)
The Cincinnati Prehospital Stroke Scale assesses facial droop, arm drift, and speech abnormality to rapidly identify stroke in the acute setting.
Question 5: A nurse is caring for a client with a chest tube following a pneumothorax. The water-seal chamber shows continuous bubbling. What does this finding indicate?
- Normal chest tube functioning
- A persistent air leak from the lung or system (Correct answer)
- Excessive fluid drainage from the pleural space
- Adequate lung re-expansion
Correct answer: A persistent air leak from the lung or system
Continuous bubbling in the water-seal chamber indicates an ongoing air leak, either from the lung itself or from a break in the closed drainage system.
Question 6: A nurse is preparing to insert a urinary catheter in a female client. After cleansing the urethral meatus and inserting the catheter 2–3 inches, urine does not flow. What is the most likely explanation?
- The catheter balloon is inflated too soon
- The catheter is inserted into the vagina (Correct answer)
- The client is dehydrated with low urine output
- The catheter is kinked in the bladder
Correct answer: The catheter is inserted into the vagina
In female clients, the catheter can easily be inadvertently inserted into the vagina rather than the urethra, requiring removal and reinsertion with a sterile catheter.
Question 7: A nurse is caring for a client who has been receiving IV vancomycin for 30 minutes when the client develops flushing and erythema of the face, neck, and upper chest. What is the priority nursing intervention?
- Stop the infusion and administer epinephrine
- Slow the infusion rate and notify the provider (Correct answer)
- Administer diphenhydramine and continue the infusion at the current rate
- Stop the infusion and initiate anaphylaxis protocol
Correct answer: Slow the infusion rate and notify the provider
Red Man Syndrome is a rate-related reaction to vancomycin, not a true allergy; slowing the infusion rate typically resolves the flushing and erythema.
RN NCLEX-RN 4
A nurse is planning care for a client with major depression who is started on fluoxetine (Prozac).
Which statement about antidepressant therapy is most important to include in discharge teaching?