NCLEX-PN NCLEX-PN Practice Test 2025

This presentation is consistent with “Red Man Syndrome” (vancomycin flushing reaction), a histamine-mediated reaction caused by rapid infusion of vancomycin. It is NOT a true allergy. The most appropriate initial nursing action is to stop the infusion immediately and notify the registered nurse or physician. The infusion can typically be restarted at a slower rate after symptoms resolve, often with premedication with diphenhydramine.

The patient has signs of digoxin toxicity: serum digoxin level above therapeutic range (2.4 ng/mL), heart rate below 60 bpm (bradycardia), and dizziness. The standard nursing protocol for digoxin is to hold the medication if the apical pulse is below 60 bpm in an adult and notify the provider. Given the supratherapeutic digoxin level and symptoms, it is critical to withhold the dose and report immediately.

For patients with type 2 diabetes, the ADA recommends an individualized meal plan emphasizing consistent carbohydrate intake distributed throughout the day, with a focus on complex carbohydrates (whole grains, vegetables, legumes) rather than simple sugars. A completely carbohydrate-free diet is not recommended. The focus should be on portion control, choosing nutrient-dense foods, and spacing meals evenly.

This is wound evisceration — protrusion of abdominal organs through an open surgical wound. This is a surgical emergency. The immediate nursing priority is to cover the exposed viscera with sterile saline-moistened dressings to prevent drying, contamination, and tissue damage. The nurse should then position the patient supine with knees bent, avoid any attempts to push the organs back in, and call for immediate medical assistance.

When a patient makes statements suggesting suicidal ideation, the most therapeutic nursing response is to directly and compassionately assess the patient’s intent by asking about thoughts of self-harm. Directly asking about suicide does NOT increase the risk — this is a common myth. Ignoring the statement, providing false reassurance, or changing the subject are non-therapeutic responses.

Using the ABCs (Airway, Breathing, Circulation) prioritization framework, a patient with a new oxygen saturation of 85% represents an immediate threat to oxygenation and requires urgent assessment and intervention. While pain, dressing changes, and medication requests are important, they do not represent immediate threats to life.

An INR of 4.5 is supratherapeutic (above the target range of 2.0–3.0), placing the patient at increased risk for bleeding. Even though the patient is not currently bleeding, the LPN should hold the warfarin dose and notify the healthcare provider for further orders. Administering the dose would further increase bleeding risk.

For an elderly patient with multiple fall risk factors, ensuring the call light is within reach and instructing the patient to call for assistance before getting up is the single most important immediate intervention. It addresses the most common cause of inpatient falls: unassisted ambulation. Raising all four side rails is considered a restraint and is inappropriate.

Following thyroidectomy, the parathyroid glands may be inadvertently damaged or removed, leading to hypoparathyroidism and resultant hypocalcemia. Classic signs include perioral tingling, numbness in extremities, Trousseau’s sign (carpopedal spasm with BP cuff inflation), and Chvostek’s sign (facial muscle twitching when tapping the facial nerve). Severe hypocalcemia can lead to laryngospasm, seizures, and cardiac arrhythmias.

This patient is experiencing signs of an acute hemolytic transfusion reaction: fever/chills, flank pain, and dark (hemoglobinuric) urine. The priority nursing action is to stop the transfusion immediately to prevent further infusion of incompatible blood. The nurse should then maintain IV access with normal saline using new tubing, notify the provider and blood bank, and send the blood bag for analysis.