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

Questions 164

NCLEX-PN

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Question 1 of 5

An adult who has cholecystitis reports clay-colored stools and moderate jaundice. The nurse knows that which is the best explanation for the presence of clay-colored stools and jaundice?

Correct Answer: D

Rationale: Clay-colored stools and jaundice result from a common bile duct obstruction, preventing bile flow to the intestines and causing bilirubin buildup in the blood. The gallbladder stores, not produces, bile, and pancreatic or gallbladder issues are less directly related.

Question 2 of 5

A young adult is admitted with a possible head injury. The car in which he was riding hit a utility pole, and the client's head hit the windshield. Baseline vital signs are BP=112/74, P=80, and R=12. The nurse checks the client an hour after admission. Which finding(s) are significant and should be reported to the charge nurse or physician immediately? Select all that apply.

Correct Answer: C,D

Rationale: Slow respirations (8) and projectile vomiting suggest increased intracranial pressure, critical in head injury, requiring immediate reporting. BP, pulse, skin, and pupil response changes are less urgent.

Question 3 of 5

The doctor has ordered Nitrostat (nitroglycerine) sublingually for a client with angina. The client should be ordered to replenish his supply every:

Correct Answer: A

Rationale: Nitroglycerin loses potency after 6 months, requiring replacement to ensure efficacy for angina relief.

Question 4 of 5

Which client is most at risk for methicillin-resistant Staphylococcus aureus infection?

Correct Answer: D

Rationale: The 80-year-old with a hemodialysis catheter in a long-term care facility (
D) is at highest risk for MRSA due to invasive devices, frequent healthcare exposure, and communal living. Others (A, B,
C) have lower risk profiles.

Question 5 of 5

A client is receiving digoxin (Lanoxin) 0.25 mg. Daily. The health care provider has written a new order to give metoprolol (Lopressor) 25 mg. B.I.D. In assessing the client prior to administering the medications, which of the following should the nurse report immediately to the health care provider?

Correct Answer: A

Rationale: Both medications decrease the heart rate. Metoprolol affects blood pressure.
Therefore, the heart rate and blood pressure must be within normal range (HR 60-100 BPM; systolic B/P over 100) in order to safely administer both medications.

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