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

Questions 164

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Question 1 of 5

A student nurse is preparing to administer the hepatitis B vaccine to a newborn. Which statement by the student nurse requires the preceptor to provide further teaching?

Correct Answer: D

Rationale: The deltoid muscle is not developed enough in newborns for intramuscular injections. The hepatitis B vaccine should be administered in the anterolateral thigh.

Question 2 of 5

A client is taking tranylcypromine (Parnate) and has received dietary instruction. Which of the following food selections would be contraindicated for this client?

Correct Answer: D

Rationale: Red wine, fava beans, and aged cheese contain tyramine and other vasopressors that can interact with MAOIs, potentially causing malignant hypertension.

Question 3 of 5

The nurse in the outpatient clinic is talking with the spouse of a client with borderline personality disorder. The client's spouse states, 'My spouse self-inflicts lacerations on the arms to stop me from traveling for business. My spouse's actions are not a serious attempt at self-harm.' Which of the following responses would be appropriate for the nurse to make?

Correct Answer: B

Rationale: Self-inflicted lacerations, even if not suicidal, indicate significant distress in borderline personality disorder and require professional assessment to ensure safety and address underlying issues.

Question 4 of 5

A client has just been diagnosed with diabetes and is admitted for insulin regulation. The client asks the nurse, 'Why do I need to be stuck so many times per day?' Which of the following statements best explains the rationale for checking the client's blood glucose level frequently?

Correct Answer: C

Rationale: Frequent blood glucose checks allow for insulin dose adjustments to maintain glycemic control. Hourly checks are excessive, fluctuations are managed not avoided, and alkalosis is unrelated to glucose elevations.

Question 5 of 5

A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action?

Correct Answer: D

Rationale: All of the options would be part of the evaluation for the effects of the large amount of fluid in a short period of time. However, the worst result is heart failure with lung congestion, so the auscultation of the lungs is the priority action.

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