NCLEX Questions, PN NCLEX Practice Exam Questions, NCLEX-PN Questions, Nurselytic

Questions 164

NCLEX-PN

NCLEX-PN Test Bank

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Extract:


Question 1 of 5

A 62-year-old client admitted to the telemetry unit after an acute myocardial infarction 3 days ago reports that the left calf is very tender and warm to the touch. Which nursing intervention is the priority?

Correct Answer: D

Rationale: Tenderness and warmth suggest deep vein thrombosis, so a neurovascular check (
D) is the priority to assess for complications. History (
A), ECG (
B), and vitals (
C) are secondary.

Question 2 of 5

The nurse is reinforcing teaching for a client with suspected Cushing syndrome who has a 24-hour urine specimen. Which of the following information should the nurse reinforce? Select all that apply.

Correct Answer: B,C

Rationale: Discarding the first void and recording the start time (
B) ensures accurate collection, and refrigerating the container (
C) preserves the sample. Catheters (
A) are not needed, all urine is collected (D is incorrect), and light protection (E) is unnecessary.

Question 3 of 5

The nurse is caring for a client who was recently prescribed methadone for chronic, severe back pain. The client indicates taking extra tablets in the last 6 hours when the pain recurred. Which findings during discharge require the client to be monitored longer in the hospital setting? Select all that apply.

Correct Answer: A,C,D

Rationale: Falling asleep (
A), vomiting (
C), and premature ventricular contractions (
D) indicate possible methadone overdose or toxicity, requiring extended monitoring. Pruritus (
B) is a common side effect, and 92% oxygen saturation (E) is not critical.

Question 4 of 5

A client who is 2 days post-operative from an appendectomy requests medication for pain. The client's vital signs are as follows: pulse 96, respirations 30, BP 130/92. The nurse should:

Correct Answer: B

Rationale: Pain medication is appropriate for a post-op client with pain and stable vitals. Anxiety may contribute, but pain should be addressed first. Bleeding checks or rechecking vitals are unnecessary without specific indicators.

Question 5 of 5

The LPN is caring for a woman who delivered a healthy 7-lb baby boy 24 hours ago. Baseline vital signs were blood pressure (BP)=90/64, temperature (T)=97.6°F, pulse (P)=72, and respirations (R)=14. Which finding is of greatest concern?

Correct Answer: D

Rationale: The significant rise in BP to 129/82 from 90/64 may indicate postpartum complications like preeclampsia, requiring immediate assessment. Red drainage, cramping, and increased water intake are normal postpartum findings.

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