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Questions 227

NCLEX-PN

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Extract:


Question 1 of 5

An adult has returned to the nursing care unit following abdominal surgery. She has an order for meperidine IM PRN for severe pain or acetaminophen #3 PO PRN for mild to moderate pain. The nurse asks the client if she is experiencing pain now, and she states, 'Yes, I am.' What is the most appropriate initial action for the nurse?

Correct Answer: C

Rationale: Assessing pain location and degree using a scale determines the appropriate medication (mild vs. severe), ensuring tailored pain management.

Extract:

Miss Helen Roller is admitted following a diagnosis of congestive heart failure. She tells you she is unable to wash herself without assistance because of shortness of breath. You notice she also has difficulty walking to the bathroom unassisted for the same reason.


Question 2 of 5

Which of the following nursing diagnosis is most important?

Correct Answer: B

Rationale: Activity intolerance due to shortness of breath is the most pressing issue affecting her daily functioning.

Extract:


Question 3 of 5

The nurse is caring for a client who underwent a mastectomy 24 hours ago. Which of the following interventions should the nurse prioritize?

Correct Answer: A

Rationale: Encouraging arm exercises prevents lymphedema and restores mobility post-mastectomy. Dependent positioning (
B) increases edema, heating pads (
C) risk tissue damage, and fluid restriction (
D) is unnecessary and harmful.

Question 4 of 5

Observation should be ordered for the client using hallucinogens because, hallucinogens

Correct Answer: B

Rationale: Hallucinogens cause altered perception, posing risks of harm due to impaired judgment, necessitating close observation. They do not typically cause respiratory depression or rapid dependence.

Question 5 of 5

Convert 8 pounds, 8 ounces to an equivalent amount in kilograms.

Correct Answer: B

Rationale: 8 pounds + 8 ounces (0.5 pounds) = 8.5 pounds. 8.5 ÷ 2.2 pounds/kg = 3.8636 kg, rounded to 3.86 kg. Other options are incorrect.

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