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National Council Licensure Examination - NCLEX-RN Questions 196–198 (page: 80)

Updated On: 9-Feb-2026

A 68-year-old woman is admitted to the hospital with chronic obstructive pulmonary disease (COPD). She is started on an aminophylline infusion. Three days later she is breathing easier. A serum theophylline level is drawn. Which of the following values represents a therapeutic level?

  1. 14 µ g/mL
  2. 25 µ g/mL
  3. 4 µ g/mL
  4. 30 µ g/mL

Answer(s): A

Explanation:

(A) The therapeutic blood level range of theophylline is 10­20 mg/mL. Therapeutic drug monitoring determines effective drug dosages and prevents toxicity. (B, D) This value is a toxic level of the drug. (C) This value is a nontherapeutic level of the drug.



A 68-year-old woman is admitted to the hospital with chronic obstructive pulmonary disease (COPD). She is started on an aminophylline infusion. Three days later she is breathing easier. A serum theophylline level is drawn. Which of the following values represents a therapeutic level?

  1. 14 µ g/mL
  2. 25 µ g/mL
  3. 4 µ g/mL
  4. 30 µ g/mL

Answer(s): A

Explanation:

(A) The therapeutic blood level range of theophylline is 10­20 mg/mL. Therapeutic drug monitoring determines effective drug dosages and prevents toxicity. (B, D) This value is a toxic level of the drug. (C) This value is a nontherapeutic level of the drug.



A 74-year-old female client is 3 days postoperative. She has an indwelling catheter and has been progressing well. While the nurse is in the room, the client states, "Oh dear, I feel like I have to urinate again!" Which of the following is the most appropriate initial nursing response?

  1. Assure her that this is most likely the result of bladder spasms.
  2. Check the collection bag and tubing to verify that the catheter is draining properly.
  3. Instruct her to do Kegel exercises to diminish the urge to void.
  4. Ask her if she has felt this way before.

Answer(s): B

Explanation:

(A) Although this may be an appropriate response, the initial response would be to assure the patency of the catheter. (B) The most frequent reason for an urge to void with an indwelling catheter is blocked tubing. This response would be the best initial response. (C) Kegel exercises while a retention catheter is in place would not help to prevent a voiding urge and could irritate the urethral sphincter. (D) Though the nurse would want to ascertain whether the client has felt the same urge to void before, the initial response should be to assure the patency of the catheter.



A 74-year-old female client is 3 days postoperative. She has an indwelling catheter and has been progressing well. While the nurse is in the room, the client states, "Oh dear, I feel like I have to urinate again!" Which of the following is the most appropriate initial nursing response?

  1. Assure her that this is most likely the result of bladder spasms.
  2. Check the collection bag and tubing to verify that the catheter is draining properly.
  3. Instruct her to do Kegel exercises to diminish the urge to void.
  4. Ask her if she has felt this way before.

Answer(s): B

Explanation:

(A) Although this may be an appropriate response, the initial response would be to assure the patency of the catheter. (B) The most frequent reason for an urge to void with an indwelling catheter is blocked tubing. This response would be the best initial response. (C) Kegel exercises while a retention catheter is in place would not help to prevent a voiding urge and could irritate the urethral sphincter. (D) Though the nurse would want to ascertain whether the client has felt the same urge to void before, the initial response should be to assure the patency of the catheter.



A client is admitted to the labor unit. On vaginal examination, the presenting part in a cephalic presentation was at station plus two. Station 12 means that the:

  1. Presenting part is 2 cm above the level of the ischial spines
  2. Biparietal diameter is at the level of the ischial spines
  3. Presenting part is 2 cm below the level of the ischial spines
  4. Biparietal diameter is 5 cm above the ischial spines

Answer(s): C

Explanation:

(A) Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. If the presenting part is above the ischial spines, the station is negative. (B) When the biparietal diameter is at the level of the ischial spines, the presenting part is generally at a +4 or +5 station. (C) Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines. If the presenting part is below the ischial spines, the station is positive. Thus, 2 cm below the ischial spines is the station +2. (D) When the biparietal diameter is above the ischial spines by 5 cm, the presenting part is usually engaged or at station 0.



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