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Questions 163

NCLEX-PN

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Question 1 of 5

The client tells the nurse she is having trouble falling asleep. What initial nursing action is least appropriate?

Correct Answer: A

Rationale: Requesting sleeping medication is premature and least appropriate without exploring non-pharmacologic interventions like back rubs, addressing concerns, or repositioning, which promote sleep naturally.

Question 2 of 5

The nurse is caring for a client who had a transurethral resection of the prostate 12 hours ago and is receiving continuous bladder irrigation. The client reports lower abdominal pain rated as an 8 on a scale of 0 to 10. Which of the following actions would be a priority for the nurse to take?

Correct Answer: D

Rationale: Severe abdominal pain post-TURP with bladder irrigation suggests possible catheter obstruction or clot formation. Verifying urine output and characteristics is the priority to ensure patency. Morphine , checking bowel movement , or oxybutynin are secondary.

Question 3 of 5

The nurse is collecting data from a client who had a transurethral resection of the prostate 10 hours ago and is receiving continuous bladder irrigation. Which of the following findings would require follow-up?

Correct Answer: D

Rationale: A 200 mL discrepancy between irrigation input and output suggests possible catheter obstruction or absorption, requiring follow-up. Normal vitals , spasm relief , and light pink urine are expected post-TURP.

Question 4 of 5

The nurse in the outpatient care facility is caring for a client who is blind. Which of the following actions should the nurse take?

Correct Answer: D

Rationale: Walking slightly ahead with the client holding the nurse's elbow is the standard technique for guiding a blind person safely. Offering food to a service dog is inappropriate, teaching cane use assumes need, and touching without warning may startle.

Question 5 of 5

The nurse is reinforcing information to a diabetic client with a new prescription for metoclopramide. Which of the following side effects must the nurse remind the client to report immediately to the health care provider? Select all that apply.

Correct Answer: A,D,E

Rationale: Metoclopramide can cause tardive dyskinesia, with symptoms like excess blinking , lip smacking , and cheek puffing , requiring immediate reporting. Dry mouth and headache are common and less urgent.

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