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

Questions 164

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Extract:


Question 1 of 5

A father suspected of child abuse tells the nurse, 'I shouldn't have grabbed him so hard. I had a really bad day at work and got all stressed out. The kid just wouldn't listen to me.' The defense mechanism used by the father is:

Correct Answer: B

Rationale: Displacement involves redirecting emotions (stress from work) onto a less threatening target (child). Projection, undoing, and compensation do not apply.

Question 2 of 5

The nurse is caring for a client with irritable bowel syndrome. Which of the following menu selections would be appropriate to offer the client?

Correct Answer: C

Rationale: Baked chicken, brown rice, and strawberries are low-FODMAP, suitable for IBS. Beans, yogurt, coffee, and broccoli are high-FODMAP, likely to trigger symptoms.

Question 3 of 5

The nurse is caring for a woman admitted with heart failure. The client has an IV running at 125 mL/hr. The client calls the nurse stating she is having difficulty breathing. The nurse observes that she is short of breath and in distress. What should the nurse do initially?

Correct Answer: A

Rationale: Raising the head of the bed improves breathing, and slowing the IV prevents fluid overload exacerbation in heart failure, addressing immediate distress.

Extract:

Laboratory reference ranges
INR
0.8-1.1


Question 4 of 5

The nurse receives report on 4 clients. Which of the following clients should the nurse see first?

Correct Answer: A

Rationale: Discomfort at an IV vancomycin site suggests possible infiltration or phlebitis, requiring immediate assessment to prevent tissue damage. INR of 1.9 is subtherapeutic but less urgent, itching/nausea are expected morphine side effects, and tubing changed 48 hours ago is within standard protocol.

Extract:


Question 5 of 5

The nurse is assessing a client who had a thyroidectomy 12 hours ago and is reporting anxiety, tingling around the mouth, and muscle twitching in the hand. Which of the following actions would be a priority for the nurse to take?

Correct Answer: D

Rationale: Anxiety, tingling, and twitching suggest hypocalcemia from parathyroid damage during thyroidectomy, requiring urgent calcium level assessment. Edema, blood gases, and vocal quality are less urgent.

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