NCLEX-PN
Free PN NCLEX Practice Questions Questions
Extract:
A 69-year-old woman has a history of heart failure. She is admitted to the emergency department with heart failure complicated by pulmonary edema.
Question 1 of 5
On admission of this patient, which of the following should be assessed first?
Correct Answer: A
Rationale: Blood pressure assessment is critical in pulmonary edema to guide treatment and assess cardiovascular status.
Extract:
Question 2 of 5
For a client with Graves' disease, which nursing intervention promotes comfort?
Correct Answer: D
Rationale: Graves' disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss.
To reduce heat intolerance and diaphoresis, the nurse should keep the client's room temperature in the low-normal range.
To replace fluids lost via diaphoresis, the nurse should encourage, not restrict, intake of oral fluids. Placing extra blankets on the bed of a client with heat intolerance would cause discomfort.
To provide needed energy and calories, the nurse should encourage the client to eat high-carbohydrate foods.
Question 3 of 5
The nurse is caring for an adult who has ulcerative colitis. When planning care, the nurse knows that which nursing diagnosis is of highest priority?
Correct Answer: A
Rationale: Ulcerative colitis causes diarrhea, leading to fluid loss and dehydration, making deficient fluid volume the highest priority to prevent systemic complications like hypovolemia.
Question 4 of 5
The physician has prescribed Cytoxan (cyclophosphamide) for a client with nephrotic syndrome. The nurse should:
Correct Answer: A
Rationale: Cyclophosphamide is nephrotoxic; extra fluids promote excretion and reduce bladder toxicity. Low-protein diets are not indicated, mild soap is unrelated, and joints are not typically inflamed in nephrotic syndrome.
Question 5 of 5
The nurse is performing a baseline assessment of a client's skin integrity. Which of the following is a key assessment parameter?
Correct Answer: D
Rationale: When assessing skin integrity, the overall risk potential for developing pressure ulcers takes priority. Overall risk encompasses existing pressure ulcers as well as potential areas for development of pressure ulcers. Family history isn't important when assessing skin integrity.