NCLEX-PN Practice Questions Quizlet
Question 1 of 5.
The nurse collects data on a client shortly after kidney transplant surgery. Which postoperative finding must the nurse report to the physician immediately?
A. Serum potassium level of 4.9 mEq/L
B. Serum sodium level of 135 mEq/L
C. Temperature of 99.2°F (37.3°C)
D. Urine output of 20 ml/hour
Explanation: Because kidney transplantation carries the risk of transplant rejection, infection, and other serious complications, the nurse should monitor the client's urinary function closely. A decrease from the normal urine output of 30 ml/hour is significant and warrants immediate physician notification. The other options are normal data collection findings.
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.