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Questions 160

NCLEX-PN

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Extract:


Question 1 of 5

A client with a suspected myocardial infarction receives nitroglycerin sublingually. Which assessment finding indicates the medication is effective?

Correct Answer: A

Rationale: Nitroglycerin relieves chest pain by dilating coronary arteries, improving blood flow to the myocardium.

Question 2 of 5

Which nursing action is most appropriate when a chest tube is inadvertently pulled from its insertion site?

Correct Answer: A

Rationale: Covering the opening prevents air entry, reducing the risk of pneumothorax until medical intervention is available.

Question 3 of 5

When performing a mental status assessment on an adult client with hypothyroidism, which behavior should the nurse expect?

Correct Answer: D

Rationale: Hypothyroidism slows metabolism, leading to impaired cognitive function, such as slowed thinking or memory issues.

Question 4 of 5

Before suctioning a client with a tracheostomy, which nursing action should the nurse perform first?

Correct Answer: C

Rationale: Administering 100% oxygen (hyperoxygenation) for 1-2 minutes before suctioning helps prevent hypoxia during the procedure, which can cause desaturation.

Question 5 of 5

The nurse is teaching a client about warfarin (Coumadin) therapy. Which statement by the client indicates a need for further teaching?

Correct Answer: C

Rationale: Ibuprofen increases bleeding risk with warfarin; the client should use acetaminophen, indicating a need for further teaching.

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