NCLEX-PN
NCLEX-PN Quizlet 2023
1. A client begins a regimen of chemotherapy. Her platelet count falls to 98,000. Which action is least likely to increase the risk of hemorrhage?
- A. Test all excreta for occult blood.
- B. Use a soft toothbrush or foam cleaner for oral hygiene.
- C. Implement reverse isolation.
- D. Avoid IM injections.
Correct answer: C
Rationale: The correct answer is to implement reverse isolation. Reverse isolation is a protective measure used to protect patients from infections, not to affect the risk of hemorrhage. Testing all excreta for occult blood (Choice A) is important to monitor for signs of internal bleeding. Using a soft toothbrush or foam cleaner for oral hygiene (Choice B) is recommended to prevent gum bleeding. Avoiding IM injections (Choice D) is crucial to reduce the risk of bleeding in a client with a low platelet count. Therefore, among the given options, implementing reverse isolation is the least likely to increase the risk of hemorrhage.
2. The factor that most determines drug distribution is:
- A. vascular perfusion of the tissue or organ.
- B. salt form.
- C. drug interactions.
- D. steady state.
Correct answer: A
Rationale: The correct answer is 'vascular perfusion of the tissue or organ.' Drug distribution is primarily determined by how well the circulatory system delivers the drug to various tissues and organs. Adequate perfusion ensures proper distribution of the drug throughout the body. While the salt form (choice B), drug interactions (choice C), and steady state (choice D) can influence drug efficacy and metabolism, they are not as crucial as vascular perfusion for the initial distribution of a drug.
3. The client is preparing to learn about the effects of isoniazid (INH). Which information is essential for the client to understand?
- A. Isoniazid should be taken with meals to reduce gastrointestinal upset.
- B. Prolonged use of isoniazid may result in dark, concentrated urine.
- C. Taking aluminum hydroxide (Maalox) with isoniazid can enhance the drug's effects.
- D. Consuming alcohol daily can increase the risk of drug-induced hepatitis.
Correct answer: D
Rationale: It is crucial for the client to understand that consuming alcohol while on isoniazid can increase the risk of drug-induced hepatitis. Hepatic damage can lead to dark, concentrated urine. To minimize gastrointestinal upset, it is recommended to take isoniazid with meals rather than on an empty stomach. Additionally, the client should avoid taking aluminum-containing antacids like aluminum hydroxide with isoniazid, as it can reduce the drug's effectiveness. Choice A is incorrect because isoniazid should not be taken on an empty stomach to help reduce GI upset. Choice B is incorrect, as prolonged use of isoniazid does not typically cause dark, concentrated urine. Choice C is incorrect as taking aluminum hydroxide with isoniazid does not enhance the drug's effects; in fact, it may decrease its effectiveness.
4. The nurse is caring for a client receiving warfarin therapy (Coumadin�) following a stroke. The client's PT/INR was completed at 7:00 A.M. prior to the morning meal with an INR reading of 4.0. Which of the following is the nurse's first priority?
- A. Call the physician to request an increase in the Coumadin� dose.
- B. Administer a vitamin K injection IM and notify the physician of the results.
- C. Assess the client for bleeding around the gums or in the stool and notify the physician of the lab results and latest dose of Coumadin�.
- D. Notify the next shift to hold the daily dose of Coumadin� scheduled for 5:00 P.M.
Correct answer: B
Rationale: In a client receiving warfarin therapy with a high INR of 4.0, the nurse's first priority is to administer a vitamin K injection intramuscularly (IM) and notify the physician of the results. An INR of 4.0 indicates excessive anticoagulation, putting the client at risk of bleeding. Vitamin K is the antidote for warfarin overdose and helps to reverse its effects. It is crucial to administer vitamin K promptly to prevent bleeding complications. Calling the physician to request an increase in the Coumadin� dose is inappropriate and dangerous in this situation, as it would further raise the INR. Assessing the client for bleeding and notifying the physician is important but not the first priority when faced with a critically high INR. Holding the daily dose of Coumadin� may be necessary after administering vitamin K, but it is not the primary action needed to address the acute high INR level.
5. The nurse is caring for a client with full-thickness burns to the left arm and trunk. What is the priority for this client?
- A. Pain management
- B. Airway assessment
- C. Fluid volume status monitoring
- D. Risk for infection prevention
Correct answer: C
Rationale: Correct! With full-thickness burns, there is a significant risk of fluid loss through the burn wound and fluid shift, leading to hypovolemia and shock. Monitoring and maintaining the client's fluid volume status is crucial to prevent complications like hypovolemic shock. Pain management (Option A) is essential but not the priority in this situation. While airway assessment (Option B) is crucial, it is typically assessed first in clients with respiratory distress. Preventing infection (Option D) is important but managing fluid volume status takes precedence in the initial care of a client with full-thickness burns.
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