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

Questions 164

NCLEX-PN

NCLEX-PN Test Bank

NCLEX Practice Test PN Questions

Extract:


Question 1 of 5

Four clients were involved in a major highway motor vehicle accident. Which client requires priority care?

Correct Answer: A

Rationale: A deviated trachea and hypotension suggest tension pneumothorax, a life-threatening condition requiring immediate decompression to restore breathing.

Question 2 of 5

The nurse is teaching a client who has a hip prosthesis following total hip replacement. Which of the following should be included in the instructions for home care?

Correct Answer: D

Rationale: Do not cross your legs. Crossing legs can exceed the 90-degree hip flexion limit, risking dislocation.

Question 3 of 5

The nurse is caring for a client at 12 weeks gestation who has a rubella titer status of nonimmune. Which of the following actions should the nurse anticipate implementing?

Correct Answer: B

Rationale: MMR is contraindicated during pregnancy due to risks to the fetus. Administering it postpartum ensures immunity for future pregnancies without harming the current pregnancy.

Question 4 of 5

The nurse is caring for a client with liver cirrhosis. Which of the following assessment findings would warrant immediate follow up?

Correct Answer: A

Rationale: Black, tarry stool (melena) indicates upper gastrointestinal bleeding, a serious complication in cirrhosis due to portal hypertension or varices, requiring immediate intervention.

Question 5 of 5

The nurse is caring for a group of clients. Which finding requires immediate action by the nurse?

Correct Answer: A

Rationale: A peripheral IV in place for 84 hours increases the risk of infection and phlebitis. Guidelines recommend changing IV sites every 72-96 hours, so this requires immediate action to remove or replace the IV.

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