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

Questions 164

NCLEX-PN

NCLEX-PN Test Bank

NCLEX PN Practice Tests Questions

Extract:


Question 1 of 5

A primigravida begins labor when her family is unavailable and she is alone. She is very upset that her family is not with her. Which approach can the nurse take to meet the client's needs at this time?

Correct Answer: A

Rationale: Allow the client to select another individual to give support. This allows her to have someone with her until her family can be with her.

Question 2 of 5

A nurse caring for a client with a central venous catheter (CVC) enters the client’s room and notes that the CVC is dislodged and lying in the client’s bed linens. The client appears cyanotic and is tachypneic and diaphoretic. Which of the following actions by the nurse are appropriate? Select all that apply.

Correct Answer: A,B,D,E

Rationale: Oxygen, occlusive dressing, vital sign monitoring, and provider notification address air embolism risk and hypoxia. High Fowler may worsen air entry; semi-Fowler is preferred.

Question 3 of 5

The nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most important measure to prevent skin breakdown?

Correct Answer: B

Rationale: Frequent turning. Frequent turning will prevent skin breakdown by relieving prolonged pressure on any one area.

Extract:

Exhibit 1
Vital signs

0800
Temperature 98.4 F (36.8 C)
Blood pressure 110/72 mm Hg
Heart rate 52/min
Respirations 16/min

Exhibit 2
Laboratory results

0800
Hematocrit
Male: 42%–52%
(0.42-0.52)
Female: 37%–47%
(0.37–0.47) 40%
(0.4)
Hemoglobin
Male: 14.0–18.0 g/dL
(140–180 g/L)
Female: 12.0–16.0 g/dL
(120–160 g/L) 14.0 g/dL
(140 g/L)
Platelets
150,000–400,000/mm3
(150–400 × 109/L) 200,000/mm3
(200 × 109/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L) 4.0 mEq/L
(4.0 mmol/L)


Exhibit 3
Medication administration record

Allergies: No known drug allergies

Medications Time
Aspirin: 81 mg by mouth, daily 0900
Docusate sodium: 100 mg by mouth, daily 0900
Lisinopril: 5 mg by mouth, daily 0900
Metoprolol: 100 mg by mouth, twice daily 0900, 1700
Simvastatin: 20 mg by mouth, daily 2000


Question 4 of 5

A client with ST segment elevation myocardial infarction is due for 0900 medications. Based on the data shown in the exhibit, which medications should the nurse administer? Select all that apply.

Correct Answer: A,C,D,E

Rationale: Aspirin (antiplatelet), lisinopril (ACE inhibitor), metoprolol (beta-blocker), and simvastatin (statin) are standard for STEMI to reduce clot formation, blood pressure, and cholesterol. Docusate is unrelated to STEMI management.

Extract:


Question 5 of 5

The nurse is teaching the client the appropriate way to use a metered dose inhaler. Which observation indicates the client needs additional teaching?

Correct Answer: C

Rationale: When using a metered dose inhaler, the client should wait 1-2 minutes between puffs to ensure proper absorption, not 30 seconds. Answer C indicates a need for additional teaching. Answers A, B, and D describe correct techniques for inhaler use.

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