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

Questions 164

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Extract:


Question 1 of 5

During the initial home visit, a nurse is discussing the care of a client newly diagnosed with Alzheimer's disease with family members. Which of these interventions would be most helpful at this time?

Correct Answer: D

Rationale: Alzheimer's disease, a progressive chronic illness, greatly challenges caregivers. The nurse can be of greatest assistance in helping the family to use communication strategies to enhance their ability to relate to the client.

Question 2 of 5

The nurse enters the room of a client with dementia and observes the client grimacing while pulling at the indwelling urinary catheter. The nurse notes blood trickling from the urinary meatus and pink-tinged urine in the urinary drainage bag. It would be a priority for the nurse to

Correct Answer: B

Rationale: Blood and grimacing suggest trauma or irritation from the catheter. Deflating the balloon allows safe removal to prevent further injury, pending provider orders.

Extract:

Laboratory reference ranges
Glucose (random)
71-200 mg/dL
(3.9–11.1 mmol/L)


Question 3 of 5

The nurse is caring for assigned clients. Which of the following clients should the nurse check first?

Correct Answer: C

Rationale: A blood glucose level of 55 mg/dL indicates severe hypoglycemia, a life-threatening condition requiring immediate intervention to prevent seizures or coma.

Extract:


Question 4 of 5

The nurse is preparing to administer the fourth dose of IV vancomycin to a client. Which set of laboratory values would alert the nurse to hold the vancomycin and notify the health care provider?

Correct Answer: D

Rationale: A vancomycin trough of 23 mg/L is above the therapeutic range (10-20 mg/L), indicating potential toxicity. Elevated creatinine (1.5 mg/dL) suggests renal impairment, which increases the risk of vancomycin accumulation and nephrotoxicity.

Question 5 of 5

The nurse is caring for a client whose peritoneal dialysis is beginning to exhibit insufficient outflow. What actions should the nurse perform initially? Select all that apply.

Correct Answer: A,B,D

Rationale: Checking for distention/constipation (
A), examining for catheter issues (
B), and repositioning to a side-lying position (
D) address common causes of outflow issues non-invasively.

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