NCLEX Questions, PN NCLEX Practice Test Questions, NCLEX-PN Questions, Nurselytic

Questions 164

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Question 1 of 5

A client is admitted with a head injury. Which vital sign assessment is most indicative of increased intracranial pressure?

Correct Answer: B

Rationale: Vital signs correlating with increased intracranial pressure are an elevated BP with a widening pulse pressure, a slow pulse rate, and an elevated temperature with involvement of the hypothalamus. Answer C relates to hypovolemia, so it is incorrect. Answers A and D do not relate to increased intracranial pressure and are therefore incorrect.

Question 2 of 5

The nurse is reinforcing instructions to a postpartum client about cord care for the newborn. Which client statement indicates a need for further teaching?

Correct Answer: D

Rationale: Securing the diaper over the cord traps moisture, increasing infection risk. The cord turning black, falling off naturally, and sponge baths are correct cord care practices.

Question 3 of 5

The nurse is caring for a client with Meniere's disease. When teaching the client about the disease, the nurse should explain that the client should avoid foods high in

Correct Answer: C

Rationale: Sodium. The client with Meniere's disease has an alteration in the balance of the fluid in the inner ear (endolymph). A low sodium diet will aid in reducing the fluid. Sodium restriction is also ordered as adjunct to diuretic therapy.

Question 4 of 5

All of the following need to be done. Which should the nurse do first?

Correct Answer: A

Rationale: Pain management for a client post-surgery today is a priority to promote comfort and recovery. Dressing changes, bed baths, and preoperative enemas are less urgent.

Question 5 of 5

The nurse is reinforcing information for a client with chronic obstructive pulmonary disease. Which statements by the client indicate an understanding of the pursed-lip breathing technique? Select all that apply.

Correct Answer: B,D

Rationale: Pursed-lip breathing involves inhaling 2 seconds through the nose (mouth closed) and exhaling 4 seconds through pursed lips to prolong exhalation and reduce air trapping in COPD.

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