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

Questions 176

NCLEX-PN

NCLEX-PN Test Bank

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Extract:


Question 1 of 5

A client reports that someone is in the room and trying to kill him. The nurse's best response is:

Correct Answer: B

Rationale: It is important to acknowledge the client's fear. The other responses deny the client's perceptions.

Question 2 of 5

A client with borderline personality disorder says to the nurse, 'You're the only one I trust around here. The others don't know what they are doing and they don't care about anyone except themselves. I only want to talk with you.' What is the priority nursing action?

Correct Answer: D

Rationale: Reinforcing boundaries (
D) addresses splitting behavior and maintains therapeutic relationships. Rotating staff (
A), assigning the preferred nurse (
B), or reassuring competence (
C) may reinforce manipulation.

Question 3 of 5

A new client is admitted with a major abscess on her thigh caused by scratching mosquito bites with dirty hands after digging in her garden. She is on isolation precautions in a private room after surgical debridement. The physician changes her dressings daily. What should the nurse wear when providing care for this client?

Correct Answer: C

Rationale: Gloves and gown are required for contact precautions due to the abscess, preventing transmission of infection.

Question 4 of 5

The nurse is contributing to the plan of care for a client with pertussis. Which of the following interventions should the nurse suggest including in the client's plan of care? Select all that apply.

Correct Answer: A, B, E

Rationale: Monitoring respiratory effort (
A), droplet precautions (
B), and frequent fluids (E) manage pertussis symptoms and transmission. Negative pressure rooms (
C) are for airborne diseases, and cough suppressants (
D) may worsen mucus clearance.

Question 5 of 5

A 70 year-old post-operative client has elevated serum BUN, HCT, Cl, and Na+. Creatinine and K+ are within normal limits. The nurse should perform additional assessments to confirm that an actual problem is:

Correct Answer: D

Rationale: Fluid volume deficit. In fluid volume deficit, serum BUN, Na+, and hematocrit may be elevated secondary to hemoconcentration.

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