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

Questions 164

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Question 1 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 2 of 5

A 2-year old is hospitalized with gastroenteritis and dehydration. Which of the following methods is best for evaluating changes in skin turgor?

Correct Answer: A

Rationale: Pinching abdominal tissue while supine is the best method to assess skin turgor in a dehydrated child, as it reflects hydration status accurately.

Question 3 of 5

The nurse is caring for a client with hyperparathyroidism who had a parathyroidectomy 4 hours ago. Which technique should the nurse use to check for complications in this client?

Correct Answer: C

Rationale: Post-parathyroidectomy, hypocalcemia is a potential complication due to reduced parathyroid hormone levels. Trousseau’s sign (
C), elicited by inflating a BP cuff to induce carpal spasm, indicates hypocalcemia, a critical complication requiring prompt intervention. The wrist hyperextension test (
A) is unrelated to hypocalcemia, and the Romberg test (
B) assesses balance, not relevant to this scenario.

Question 4 of 5

During the evaluation phase for a client, the nurse should focus on

Correct Answer: B

Rationale: The client's status, progress toward goal achievement, and ongoing re-evaluation. Evaluation focuses on assessing progress and adjusting the care plan.

Question 5 of 5

A client returns from the operating room after a right orchiectomy. For the immediate post-operative period the nursing priority would be to

Correct Answer: B

Rationale: Due to the location of the incision, pain management is the priority. Bladder spasms are more related to prostate surgery.

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