NCLEX Questions, ATI NCLEX-PN Practice Questions Questions, NCLEX-PN Questions, Nurselytic

Questions 157

NCLEX-PN

NCLEX-PN Test Bank

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Extract:


Question 1 of 5

The client receiving a continuous heparin drip complains of sudden chest pain on inspiration and tells the nurse, 'Something is really wrong with me.' Which intervention should the nurse implement first?

Correct Answer: C

Rationale: Sudden pleuritic chest pain suggests pulmonary embolism, a heparin complication; assessing lung sounds is the first step.

Question 2 of 5

The client diagnosed with a brain tumor who had radiation treatment and developed alopecia asks, 'When will my hair grow back?' Which statement is the nurse's best response?

Correct Answer: C

Rationale: Radiation-induced alopecia may be permanent or take months to regrow, depending on dose; honesty prepares the client.

Question 3 of 5

The nurse is incorporating complementary therapies in the routines of residents of a long-term care facility. Which information should the nurse consider when matching the clients with the therapy? Select all that apply.

Correct Answer: A,B,C,E

Rationale: Matching therapies requires considering client preferences, likes/dislikes, therapy benefits, and physical/mental abilities for effectiveness and adherence. Significant other’s concerns are secondary unless they impact care.

Question 4 of 5

Which assessment information is the most critical indicator of a neurological deficit?

Correct Answer: B

Rationale: Level of consciousness is the most sensitive indicator of neurological status, reflecting brain function.

Question 5 of 5

The client with a closed head injury is admitted to the neurointensive care department following a motor-vehicle accident. Which goal is an appropriate short-term goal for the client?

Correct Answer: C

Rationale: Maintaining ICP <15 mm Hg is a critical short-term goal in head injury to prevent brain damage, per neuro ICU standards.

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