NCLEX RN PEARSON UPDATED EXAM
SCRIPT ALL TESTED QUESTIONS AND WELL
ELABORATED ANSWERS WITH
RATIONALES REVIEW SHEET EXPERT
APPROVED TOP RATED
⩥ N/A
TOP: Client Needs Category: Physiological Integrity (Physiological
AdaptationIllness Management) MSC: Integrated Process: Nursing
Process (Analysis)
17. An unknown unconscious client with an elevated temperature is
ordered intravenous penicillin. What is the best action for the nurse to
take?
a.
Administer the medication.
b.
,Check the chart for allergies.
c.
Look for medical alert identification.
d.
Notify the nursing supervisor..
Answer: C
Allergies need to be identified before medications are administered. This
client cannot talk and is unknown, so a chart cannot be retrieved. Clients
with allergies are taught to carry medical alert identification.
DIF: Cognitive Level: Application/Applying or higher
⩥ N/A
TOP: Client Needs Category: Safe and Effective Care Environment
(Safety and Infection ControlAccident/Injury Prevention)
MSC: Integrated Process: Nursing Process (Implementation)
,18. A nurse suspects that a client has serum sickness. For which
manifestation does the nurse assess the client?
a.
Joint pain
b.
Allergic rhinitis
c.
Stridor
d.
Wheezing.
Answer: A
, Serum sickness is a delayed reaction, type III. Signs and symptoms
include fever, arthralgia, fever, rash, malaise, and lymphadenopathy. The
other signs and symptoms are related to type I allergic reactions.
DIF: Cognitive Level: Application/Applying or higher
⩥ N/A
TOP: Client Needs Category: Physiological Integrity (Physiological
AdaptationPathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
19. The nurse enters a clients room and observes the manifestations
shown below. What action should the nurse take first?
a.
Prepare to administer diphenhydramine (Benadryl).
b.
Prepare to administer epinephrine.
SCRIPT ALL TESTED QUESTIONS AND WELL
ELABORATED ANSWERS WITH
RATIONALES REVIEW SHEET EXPERT
APPROVED TOP RATED
⩥ N/A
TOP: Client Needs Category: Physiological Integrity (Physiological
AdaptationIllness Management) MSC: Integrated Process: Nursing
Process (Analysis)
17. An unknown unconscious client with an elevated temperature is
ordered intravenous penicillin. What is the best action for the nurse to
take?
a.
Administer the medication.
b.
,Check the chart for allergies.
c.
Look for medical alert identification.
d.
Notify the nursing supervisor..
Answer: C
Allergies need to be identified before medications are administered. This
client cannot talk and is unknown, so a chart cannot be retrieved. Clients
with allergies are taught to carry medical alert identification.
DIF: Cognitive Level: Application/Applying or higher
⩥ N/A
TOP: Client Needs Category: Safe and Effective Care Environment
(Safety and Infection ControlAccident/Injury Prevention)
MSC: Integrated Process: Nursing Process (Implementation)
,18. A nurse suspects that a client has serum sickness. For which
manifestation does the nurse assess the client?
a.
Joint pain
b.
Allergic rhinitis
c.
Stridor
d.
Wheezing.
Answer: A
, Serum sickness is a delayed reaction, type III. Signs and symptoms
include fever, arthralgia, fever, rash, malaise, and lymphadenopathy. The
other signs and symptoms are related to type I allergic reactions.
DIF: Cognitive Level: Application/Applying or higher
⩥ N/A
TOP: Client Needs Category: Physiological Integrity (Physiological
AdaptationPathophysiology)
MSC: Integrated Process: Nursing Process (Assessment)
19. The nurse enters a clients room and observes the manifestations
shown below. What action should the nurse take first?
a.
Prepare to administer diphenhydramine (Benadryl).
b.
Prepare to administer epinephrine.
