NCLEX Questions, NCLEX Trainer Test 1 Questions, NCLEX-PN Questions, Nurselytic

Questions 157

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Question 1 of 5

A nurse is caring for a 2 year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to

Correct Answer: A

Rationale: A cerebral vascular accident. Polycythemia occurs as a physiological reaction to chronic hypoxemia, increasing the risk of thromboembolic events like cerebrovascular accidents, which can manifest as seizures.

Question 2 of 5

The nurse is inserting an indwelling urinary catheter in an adult woman. The nurse locates landmarks before inserting the catheter. The urethral opening is located:

Correct Answer: C

Rationale: The female urethral opening is located between the clitoris and vagina, a key landmark for catheter insertion to avoid incorrect placement.

Question 3 of 5

The nurse is caring for a client with a pressure ulcer on the heel that is covered with black hard tissue. Which would be an appropriate goal in planning care for this client?

Correct Answer: D

Rationale: Keep the tissue intact. Dry, intact eschar requires no intervention unless signs of infection appear.

Question 4 of 5

The nurse is teaching a client with a new diagnosis of epilepsy about phenytoin (Dilantin). Which of the following statements by the client indicates a need for further teaching?

Correct Answer: D

Rationale: Stopping phenytoin when seizures stop is incorrect, as epilepsy often requires lifelong treatment to prevent recurrence. Options A, B, and C are correct: oral hygiene prevents gingival hyperplasia, rashes may indicate hypersensitivity, and grapefruit juice does not significantly affect phenytoin.

Question 5 of 5

The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin lispro (Humalog) 8 units before meals. Which of the following symptoms should the nurse report immediately?

Correct Answer: B

Rationale: Sweating and confusion indicate hypoglycemia, a medical emergency with insulin lispro. Options A, C, and D are less urgent.

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