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

Questions 164

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Question 1 of 5

Following a motor vehicle accident, the client does not know where he is or what year it is and has short-term memory impairment. Which nursing action is most appropriate?

Correct Answer: B

Rationale: Simple directions accommodate memory impairment and disorientation, enhancing comprehension and safety post-accident.

Question 2 of 5

The nurse is caring for a client with type 2 diabetes mellitus who is receiving a thiazolidinedione. Which of the following findings would require immediate follow-up?

Correct Answer: A

Rationale: Thiazolidinediones (eg, rosiglitazone, pioglitazone) are oral antidiabetic medications used to manage hyperglycemia in clients with type 2 diabetes mellitus. Thiazolidinediones increase the sensitivity of insulin receptors, which improves insulin efficacy and prevents large rises in blood glucose after meals. It is a priority for the nurse to report signs of heart failure (eg, bilateral pitting edema, rapid weight gain, crackles) to the health care provider because thiazolidinediones can cause heart failure due to fluid retention. The client may require a lower thiazolidinedione dose or therapy with a different oral antidiabetic agent (eg, metformin).

Question 3 of 5

The nurse is providing pin site care for an adult who is in skeletal traction. What should the nurse do when providing pin site care?

Correct Answer: D

Rationale: Pin site care involves cleaning with soap and water to prevent infection and applying antibiotic ointment as ordered to reduce bacterial growth, per standard protocols.

Question 4 of 5

The home health hospice nurse visits a client who is newly prescribed extended-release oxycodone 40 mg orally, scheduled every 12 hours to treat severe chronic cancer pain. Which information is most important to reinforce to the client’s caregiver?

Correct Answer: A

Rationale: Around-the-clock dosing maintains pain control in cancer, preventing peaks and troughs. Combining with immediate-release opioids is common, dosage changes require provider orders, and tapering is less critical in terminal care.

Question 5 of 5

While caring for a client in skeletal traction, which tasks can the nurse assign to experienced unlicensed assistive personnel to help prevent immobility hazards? Select all that apply.

Correct Answer: A,D,E

Rationale: Assisting with range of motion, reapplying compression devices, and reminding about spirometry are within UAP scope and prevent immobility issues. Assessing extremities and logrolling require nursing judgment.

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