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

Questions 164

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Extract:


Question 1 of 5

All of the following clients need attention. Which one should the nurse go to first?

Correct Answer: A

Rationale: Severe headache and blurred vision in spinal cord injury suggest autonomic dysreflexia, a life-threatening emergency, prioritizing immediate attention over turning, examination, or ambulation.

Question 2 of 5

The nurse is caring for a client with diabetic ketoacidosis (DKA). Which of the following acid-base imbalances would the nurse expect to assess in this client?

Correct Answer: A

Rationale: DKA causes metabolic acidosis due to excess ketone production from fat breakdown. Alkalosis and respiratory imbalances are not typical in DKA.

Question 3 of 5

The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring?

Correct Answer: D

Rationale: Pitting edema indicates fluid overload, a potential mannitol complication due to fluid shifts. High urine output is expected, and improving Glasgow Coma Scale is a therapeutic effect.

Question 4 of 5

A client comes into the community health center upset and crying stating 'I will die of cancer now that I have this disease.' And then the client hands the nurse a paper with one word written on it: 'Pheochromocytoma.' Which response should the nurse state initially?

Correct Answer: A

Rationale: Pheochromocytomas usually aren't cancerous (malignant). But they may be associated with cancerous tumors in other parts of the body, providing reassurance and accurate information to alleviate the client's fear.

Question 5 of 5

A 2-year-old child seen in the emergency department is dehydrated and malnourished. The child’s parent reports that the child has had diarrhea for the past 2 weeks. Which observation is of most concern to the nurse?

Correct Answer: D

Rationale: Leaving young children in the care of a 9-year-old poses significant safety risks, indicating neglect and requiring immediate intervention. Job constraints, lack of concern, and single status are concerning but less immediately dangerous.

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