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

Questions 164

NCLEX-PN

NCLEX-PN Test Bank

NCLEX PN Practice Test Questions

Extract:


Question 1 of 5

A nurse is caring for a client 2 days after surgical creation of an arteriovenous fistula in the forearm. Which finding should the nurse report immediately to the health care provider?

Correct Answer: C

Rationale: Pale skin in the hand (
C) suggests vascular compromise, risking fistula failure or ischemia, requiring immediate reporting. Edema (
A) is common, a swooshing sound (
B) indicates patency, and mild pain (
D) is expected.

Question 2 of 5

A visiting family member of a hospitalized client reports sudden onset of a headache and numbness in half of the body. The visitor asks the nurse to take a blood pressure reading. What is the most appropriate response by the nurse?

Correct Answer: B

Rationale: Sudden headache and hemibody numbness suggest a possible stroke, a medical emergency requiring immediate evaluation. Initiating protocol to transfer the visitor to the emergency department (
B) ensures timely care. Lying down (
A), taking blood pressure (
C), or calling a provider (
D) delays critical intervention.

Question 3 of 5

A client taking Zoloft (sertraline) tells the nurse that she has also been taking St. John's wort. The nurse should report this information to the doctor because:

Correct Answer: B

Rationale: St. John's wort can induce the metabolism of Zoloft, potentially reducing its effectiveness, so the doctor may need to adjust the dose. Answer A is incorrect as they do not have opposing effects. Answer C is incorrect as St. John's wort has pharmacological effects. Answer D is incorrect as increasing the dose may not be necessary.

Question 4 of 5

A young adult is admitted with a possible head injury. The car in which he was riding hit a utility pole, and the client's head hit the windshield. Baseline vital signs are BP=112/74, P=80, and R=12. The nurse checks the client an hour after admission. Which finding(s) are significant and should be reported to the charge nurse or physician immediately? Select all that apply.

Correct Answer: C,D

Rationale: Slow respirations (8) and projectile vomiting suggest increased intracranial pressure, critical in head injury, requiring immediate reporting. BP, pulse, skin, and pupil response changes are less urgent.

Extract:

Laboratory results
WBC
5000-10,000/mm³
(5-10 × 10⁹/L) 1400/mm3
(1.4 × 109/L)
Hemoglobin
Male: 14-18 g/dL
(140-180 g/L)

Female: 12-16 g/dL
(120-160 g/L) 10 g/dL
(100 g/L)
Absolute neutrophil count
2500-8000/mm³
(2.5-8 × 10⁹/L) 500/mm3
(0.5 × 109/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L) 3.4 mEq/L
(3.4 mmol/L)
Platelets
150,000-400,000/mm³
(150-400 × 10⁹/L) 150,000/mm3
(150 × 109/L)


Question 5 of 5

A client in the hospital is receiving chemotherapy. Based on today’s blood laboratory results, which of the following actions should the nurse take?

Correct Answer: D

Rationale: Chemotherapy often causes neutropenia, increasing infection risk. A face mask (
D) protects the client. Hematuria (
A), peaked T waves (
B), and epoetin (
C) address other issues not directly indicated.

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