NCLEX-PN
NCLEX PN Prep Questions Questions
Extract:
Question 1 of 5
A client is admitted to the hospital with a diagnosis of deep vein thrombosis. During the initial assessment, the client complains of sudden shortness of breath. The SaO2 is 87. The priority nursing assessment at this time is
Correct Answer: D
Rationale: Lung sounds are critical assessments at this point. The nurse should be alert to crackles or a pleural friction rub, highly suggestive of a pulmonary embolism.
Question 2 of 5
The nurse is caring for a client with trigeminal neuralgia (tic douloureux). To assist the client with nutrition needs, the nurse should
Correct Answer: A
Rationale: Offer small meals of high calorie soft food. High-calorie soft foods minimize chewing, providing nourishment with less pain.
Question 3 of 5
The clinic nurse has contributed to the teaching plan for the following 6 clients. The nurse reinforces the teaching by instructing which client to avoid the Valsalva maneuver when defecating? Select all that apply.
Correct Answer: A,C,E,F
Rationale: The Valsalva maneuver increases intracranial pressure (head injury), cardiac strain (post-MI), intra-abdominal pressure (portal hypertension), and intraocular pressure (post-cataract surgery), risking complications. Mammoplasty and pancreatic cancer have less direct risks.
Question 4 of 5
The nurse is caring for a client with deep venous thrombosis of the lower extremity. Which of the following findings would the nurse expect to observe? Select all that apply.
Correct Answer: B,C,D
Rationale: DVT causes inflammation, leading to warmth, redness, pain, and edema in the affected extremity. Dry, shiny, hairless skin and cyanosis are more typical of arterial insufficiency, not DVT.
Question 5 of 5
The nurse is preparing to administer ear drops to an adult client. It would require follow-up if the nurse
Correct Answer: B
Rationale: Placing the dropper into the ear canal risks injury and contamination. Ear drops should be instilled by holding the dropper above the canal. Other actions are correct: room-temperature drops prevent discomfort, pulling the pinna straightens the canal, and a cotton ball retains the medication.