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

Questions 164

NCLEX-PN

NCLEX-PN Test Bank

NCLEX PN Practice Tests Questions

Extract:


Question 1 of 5

During morning rounds, the nurse notices that a client who was admitted 3 days ago with hepatic encephalopathy is sleepy and confused. The client is scheduled for discharge later today. Which interventions are appropriate for the nurse to implement? Select all that apply.

Correct Answer: A,D,E

Rationale: Comparing mental status, monitoring ammonia, and observing for asterixis (hand flapping) assess worsening encephalopathy, delaying discharge. Ambulation is unsafe, and holding lactulose may worsen symptoms.

Question 2 of 5

The client is scheduled for a glucose tolerance test. Place in ordered response the correct sequence for performance of this test.

Correct Answer: B,C,D,A,E

Rationale: When placing in chronological order, the nurse should: tell the client to increase the amount of carbohydrates for three days prior to the exam; instruct the client to remain NPO after midnight the day of the exam; obtain a fasting blood glucose level; instruct the client to drink a 75 gm glucose solution; and obtain a two-hour post-prandial glucose level. The candidate is asked to place answers in a logical sequence. Think about the natural order of the question.

Question 3 of 5

The nurse is preparing a client for cervical uterine radiation implant insertion. Which will the nurse expect to be included in the teaching plan?

Correct Answer: B

Rationale: A catheter allows urine elimination without possible disruption of the implant. There is usually no restriction on TV or phone use, so answer A is incorrect. The client is placed on a low residue diet, so answer C is incorrect. The client's radiation is not internal; therefore, there are no special precautions with excretions, making answer D incorrect.

Question 4 of 5

The nurse in the outpatient clinic is talking with a client who was diagnosed with hypertension 6 months ago. The client's current blood pressure is 170/94 mm Hg. Which of the following questions would be most important for the nurse to ask?

Correct Answer: D

Rationale: A major disadvantage of long-term management of hypertension is poor adherence to the treatment plan. Blood pressure medications can have unpleasant adverse effects, including fatigue, dizziness, and erectile dysfunction. In addition, clients may stop taking the medications when they believe their blood pressure has returned to normal range or if medications are expensive. Abrupt discontinuation of prescribed antihypertensive medications can lead to hypertensive crisis, a life-threatening emergency characterized by severely elevated blood pressure (ie, systolic ≥180 mm Hg and/or diastolic ≥120 mm Hg).
To prevent complications (eg, end organ damage), the nurse should determine if the client has been taking the medications consistently (Option 4). There may be a need for a dosage change or addition of another medication.

Question 5 of 5

An adult woman who broke her right ankle is seen in the physician's office one week after the cast was applied. Which observation indicates to the office nurse that the client is using crutches correctly?

Correct Answer: A

Rationale: The four-point crutch gait (left crutch, right foot, right crutch, left foot) is stable and correct for a non-weight-bearing right ankle, ensuring balance and safety.

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