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

Questions 164

NCLEX-PN

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Extract:


Question 1 of 5

A client was struck on the head by a baseball bat during a robbery attempt. The nurse gives shift report to the oncoming nurse and conveys that the client's current Glasgow Coma Scale score is a '10.' Which other information is most important for the reporting nurse to include?

Correct Answer: B

Rationale: A decrease in Glasgow Coma Scale score from 11 to 10 in one hour indicates worsening neurological status, possibly due to increasing intracranial pressure, requiring urgent reporting.

Question 2 of 5

The nurse enters the room of a client with dementia and observes the client grimacing while pulling at the indwelling urinary catheter. The nurse notes blood trickling from the urinary meatus and pink-tinged urine in the urinary drainage bag. It would be a priority for the nurse to

Correct Answer: B

Rationale: Blood and grimacing suggest trauma or irritation from the catheter. Deflating the balloon allows safe removal to prevent further injury, pending provider orders.

Question 3 of 5

An adult client is receiving oxygen at 6 L/min. The client asks the nurse why the oxygen is running through bubbling water. What should be included in the nurse's reply?

Correct Answer: B

Rationale: Bubbling water in oxygen delivery systems humidifies the oxygen, preventing mucosal drying. It doesn't cool oxygen, prevent fires, or reduce infections.

Question 4 of 5

An infant is to be admitted with severe diarrhea. Which room assignment is best for this infant?

Correct Answer: A

Rationale: A private room prevents transmission of infectious diarrhea to others. Proximity to the station, sharing with a non-infectious patient, or another diarrheal infant increases risks.

Question 5 of 5

The nurse is assigning client care tasks to unlicensed assistive personnel. Which statement by the nurse is appropriate?

Correct Answer: A

Rationale: Assigning vital signs for multiple clients is clear, specific, and within the UAP's scope of practice, ensuring safe delegation.

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