NCLEX Questions, PN NCLEX Practice Exam Questions, NCLEX-PN Questions, Nurselytic

Questions 164

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Extract:


Question 1 of 5

The health care provider (HCP) explains the risks and benefits of a procedure to the client through an interpreter. The HCP leaves after asking the nurse to witness the client's signature on the consent. The interpreter and client now have a lengthy discussion in the foreign language. The nurse should take which action at this time?

Correct Answer: A

Rationale: Asking the interpreter to explain the discussion (
A) ensures the nurse understands any concerns or clarifications, verifying informed consent. Gestures (
B) are unreliable, the interpreter witnessing (
C) is inappropriate, and noting interpreter use (
D) is insufficient without understanding the discussion.

Question 2 of 5

The nurse in the emergency department is caring for a client who has facial lacerations, a suspected fracture of the arm, and multiple bruises at various stages of healing. The client's spouse is at the bedside and appears angry. Which of the following actions would be a priority for the nurse take?

Correct Answer: B

Rationale: Multiple bruises at various stages suggest possible abuse, so talking privately with the client (
B) is the priority to assess safety. Social services (
A) may follow, but immediate safety assessment comes first. Treating injuries (C,
D) is secondary.

Question 3 of 5

A pregnant client who is at 34 weeks gestation is diagnosed with a pulmonary embolism (PE). Which of these medications would the nurse anticipate the provider ordering?

Correct Answer: C

Rationale: Heparin infusion to maintain the PTT at 1.5-2.5 times the control value. In pregnant women with pulmonary embolism, heparin is preferred over warfarin due to warfarin's teratogenic effects. A continuous heparin infusion is typically used to achieve therapeutic anticoagulation, monitored by maintaining the PTT at 1.5-2.5 times the control value.

Question 4 of 5

The nurse is caring for a pregnant woman with pregnancy induced hypertension (PIH) receiving magnesium sulfate intravenously. In assessing the client, it is noted that respirations are 12, pulse and blood pressure have dropped significantly, and 8 hour output is 200 ml. What should the nurse do first?

Correct Answer: C

Rationale: The assessments strongly suggest magnesium sulfate toxicity. The nurse must discontinue the IV immediately and take measures to ensure the safety of the client.

Question 5 of 5

The clinic nurse is caring for a client who had cataract surgery with intraocular lens implantation 2 days ago. Which client report requires priority intervention?

Correct Answer: C

Rationale: Itching in the affected eye (
C) may indicate infection or complications post-cataract surgery, requiring immediate intervention. Blurry vision (
A) is expected initially, constipation (
B) is unrelated, and sleeping elevated (
D) is appropriate.

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