NCLEX Questions, PN NCLEX Practice Exam Questions, NCLEX-PN Questions, Nurselytic

Questions 164

NCLEX-PN

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Question 1 of 5

An 86-year-old client with diabetes and gastroparesis has had repeated hospitalizations for aspiration pneumonia following a stroke and is now hospitalized with altered level of consciousness. Which nursing action is most appropriate to decrease the client's risk for developing aspiration pneumonia?

Correct Answer: B

Rationale: The side-lying position (
B) reduces aspiration risk by preventing reflux into the airway, especially in clients with altered consciousness. Assessing breath sounds (
A), oxygen titration (
C), and repositioning (
D) are supportive but less effective for prevention.

Question 2 of 5

A gravida para 1 reports that a prior pregnancy ended in loss of the baby early in the pregnancy. Which of the following instructions should be given to the client?

Correct Answer: D

Rationale: Reporting nausea and vomiting is important, as severe symptoms could indicate complications like hyperemesis gravidarum, especially given the history of pregnancy loss.

Question 3 of 5

The LPN is caring for a woman who delivered a healthy 7-lb baby boy 24 hours ago. Baseline vital signs were blood pressure (BP)=90/64, temperature (T)=97.6°F, pulse (P)=72, and respirations (R)=14. Which finding is of greatest concern?

Correct Answer: D

Rationale: The significant rise in BP to 129/82 from 90/64 may indicate postpartum complications like preeclampsia, requiring immediate assessment. Red drainage, cramping, and increased water intake are normal postpartum findings.

Question 4 of 5

The nurse prepares to administer a cleansing enema to a client with constipation. Which interventions are appropriate? Select all that apply.

Correct Answer: A,B,C,E

Rationale: Lubricating the tube (
A), left lateral positioning (
B), retaining the enema (
C), and pausing for cramping (E) are correct for safe administration. Refrigerating the solution (
D) is incorrect; it should be at body temperature.

Question 5 of 5

A 24-year-old female client is prescribed isotretinoin for severe cystic acne. Which instruction is most important for the nurse to reinforce?

Correct Answer: D

Rationale: Isotretinoin is highly teratogenic, so using two forms of contraception (
D) is critical to prevent pregnancy. Sunscreen (
C) is important for photosensitivity, but contraception is the priority.

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