NCLEX-PN Practice Questions Quizlet
Question 1 of 5.
A client is to have an epidural block to relieve labor pain. The nurse anticipates that the anesthesiologist will inject the anesthetic agent into the:
A. subarachnoid space
B. area between the subarachnoid space and the dura mater
C. area between the dura mater and the ligamentum flavum
D. ligamentum flavum
Explanation: For an epidural block, the nurse should anticipate that the anesthesiologist will inject a local anesthetic agent into the epidural space, located between the dura mater and the ligamentum flavum in the lumbar region of the spinal column. When administering a spinal block, the anesthesiologist injects the anesthetic agent into the subarachnoid space. The ligamentum flavum and the area between the subarachnoid space and the dura mater are inappropriate injection sites.
Question 2 of 5.
The nurse is caring for an adult who is being admitted to the unit for detoxification from alcohol. Which comment is the client most likely to make at this time?
A. I am so sorry for any trouble I've caused my family.
B. I'm not really an alcoholic you know. I'm doing this to please my wife.
C. I am so embarrassed. I know drinking is wrong.
D. My friends and family all tell me I am not an alcoholic.
Explanation: Denial is common in early alcohol detoxification, with clients often minimizing their problem or attributing treatment to external pressures.
Question 3 of 5.
A cooling blanket has been ordered for an adult who has a head injury and is running high fevers. The client starts shivering. What action is most appropriate for the LPN?
A. Add more blankets to warm up the client
B. Report immediately to the charge nurse
C. Increase the temperature of the cooling blanket
D. Continue to monitor the client because shivering is expected
Explanation: Shivering indicates the cooling blanket may be too cold, risking complications; reporting to the charge nurse ensures proper adjustment.
Question 4 of 5.
An adult is taking warfarin daily. The client's international normalized ratio (INR) is 2.4. Which nursing action is most appropriate?
A. Increase the dose of warfarin by 2 mg
B. Withhold the warfarin and notify the physician
C. Administer the warfarin as ordered
D. Call the physician for a decrease in dosage
Explanation: An INR of 2.4 is within the therapeutic range (2.0-3.0) for anticoagulation, indicating the dose should be continued as ordered.
Question 5 of 5.
The nurse is caring for a client who is prescribed cholestyramine (Questran). Which comment by the client is of most concern to the nurse?
A. I have a grapefruit almost every day for breakfast.'
B. My muscles were very tired after exercising yesterday.'
C. I have lost three pounds in the last two weeks.'
D. When the nurse drew my blood last time, he left a bruise.'
Explanation: Muscle fatigue may indicate myopathy, a rare but serious side effect of cholestyramine, requiring immediate evaluation. Grapefruit, weight loss, and bruising are not directly related to cholestyramine risks.