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

Questions 164

NCLEX-PN

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Extract:


Question 1 of 5

A client is brought to the emergency room following a motor vehicle accident. When assessing the client one-half hour after admission, the nurse notes several physical changes. Which finding would require the nurse's immediate attention?

Correct Answer: C

Rationale: tracheal deviation. The deviated trachea is a sign that a mediastinal shift has occurred. This is a medical emergency.

Question 2 of 5

A visiting family member of a hospitalized client reports sudden onset of a headache and numbness in half of the body. The visitor asks the nurse to take a blood pressure reading. What is the most appropriate response by the nurse?

Correct Answer: B

Rationale: Sudden headache and hemibody numbness suggest a possible stroke, a medical emergency requiring immediate evaluation. Initiating protocol to transfer the visitor to the emergency department (
B) ensures timely care. Lying down (
A), taking blood pressure (
C), or calling a provider (
D) delays critical intervention.

Question 3 of 5

The nurse is teaching the client regarding bladder retraining. The ability to remain continent depends on the:

Correct Answer: C

Rationale: The central nervous system coordinates bladder control, integrating sensory input and voluntary control for continence. Other systems play secondary roles.

Question 4 of 5

The nurse is caring for a client with COPD who becomes dyspneic. The nurse should

Correct Answer: C

Rationale: Use pursed-lip breathing during periods of dyspnea to control rate and depth of respiration and improve respiratory muscle coordination.

Question 5 of 5

Which situations require that the nurse report to an appropriate authority? Select all that apply.

Correct Answer: B,C,D,E

Rationale: Gonorrhea (
B) and syphilis (E) are reportable diseases, regardless of HIPAA. Suspected abuse in a teenager (
C) or elderly client (
D) mandates reporting, despite provider or client denial. Cupping (
A) is a cultural practice, not abuse.

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