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

Questions 164

NCLEX-PN

NCLEX-PN Test Bank

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Extract:


Question 1 of 5

During the evaluation phase for a client, the nurse should focus on

Correct Answer: B

Rationale: The client's status, progress toward goal achievement, and ongoing re-evaluation. Evaluation focuses on assessing progress and adjusting the care plan.

Question 2 of 5

The nurse is observing a staff member preparing regular insulin and NPH insulin in 1 syringe. The nurse should intervene if the staff member is observed

Correct Answer: A

Rationale: When mixing regular and NPH insulin, regular (clear) insulin is drawn first to prevent contamination with NPH (cloudy) insulin, which could alter its action. Drawing NPH after regular (
A) is incorrect and requires intervention. Injecting air into vials (
B) follows the same order (NPH then regular), which is correct. Needle contact with the vial (
C) is poor technique but less critical than incorrect insulin order.

Question 3 of 5

A visiting family member of a hospitalized client reports sudden onset of a headache and numbness in half of the body. The visitor asks the nurse to take a blood pressure reading. What is the most appropriate response by the nurse?

Correct Answer: B

Rationale: Sudden headache and hemibody numbness suggest a possible stroke, a medical emergency requiring immediate evaluation. Initiating protocol to transfer the visitor to the emergency department (
B) ensures timely care. Lying down (
A), taking blood pressure (
C), or calling a provider (
D) delays critical intervention.

Question 4 of 5

A client is brought to the emergency room following a motor vehicle accident. When assessing the client one-half hour after admission, the nurse notes several physical changes. Which finding would require the nurse's immediate attention?

Correct Answer: C

Rationale: tracheal deviation. The deviated trachea is a sign that a mediastinal shift has occurred. This is a medical emergency.

Question 5 of 5

A child with a high level of school absenteeism is diagnosed with separation anxiety disorder. The school nurse should remind the child’s parent to take what action?

Correct Answer: C

Rationale: Gradual exposure to school, starting with partial attendance (
C), helps desensitize the child to separation anxiety. Staying home (
A) reinforces avoidance, schoolwork at home (
B) delays reintegration, and parental presence (
D) hinders independence.

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