NCLEX-PN
NCLEX PN Prep Questions Questions
Extract:
Question 1 of 5
A client is 2 days post operative. The vital signs are: BP - 120/70, HR - 110 BPM, RR - 26, and Temperature - 100.4 degrees Fahrenheit (38 degrees Celsius). The client suddenly becomes profoundly short of breath, skin color is gray. Which assessment would have alerted the nurse first to the client's change in condition?
Correct Answer: B
Rationale: Tachypnea is one of the first clues that the client is not oxygenating appropriately. The compensatory mechanism for decreased oxygenation is increased respiratory rate.
Question 2 of 5
The nurse is reinforcing discharge teaching to several clients with new prescriptions. Which instructions by the nurse about medication administration are correct? Select all that apply.
Correct Answer: A,D
Rationale: Salt substitutes (potassium-based) can cause hyperkalemia with valsartan. Ethambutol can cause optic neuritis, requiring vision change reports. Levofloxacin with antacids reduces absorption. Sucralfate is taken before meals to coat the stomach. Rifampin's red-orange urine is normal, not reportable.
Question 3 of 5
An adult is admitted with Guillain-Barré syndrome. On day 3 of hospitalization, the client's muscle weakness worsens, and he is no longer able to stand with support. He is also having difficulty swallowing and talking. The priority in the nursing care plan at this time is to prevent which problem?
Correct Answer: A
Rationale: Difficulty swallowing increases aspiration risk, making aspiration pneumonia the priority. Other complications are secondary in this acute phase.
Question 4 of 5
The family of a frail elderly man who is bedridden asks the nurse what they can do to prevent bedsores. Which response by the nurse is best?
Correct Answer: B
Rationale: Turning every two hours relieves pressure on bony prominences, preventing pressure ulcers. Getting out of bed may be infeasible, and rubbing or sheet changes are less effective.
Question 5 of 5
Which client would be at greatest risk for a fat emboli following a fracture?
Correct Answer: C
Rationale: Fat emboli occur more frequently with long bone or pelvic fractures and usually in young adults age 20-30. Answers A, B, and D are not high-risk incidents and do not fall in the greater risk category, so they are incorrect.