NCLEX-PN
Free PN NCLEX Practice Questions Questions
Extract:
Question 1 of 5
The nurse assesses a client who gave birth 24 hours earlier. Which of the following findings reveals the need for further evaluation?
Correct Answer: B
Rationale: During the early postpartum period, lochia rubra should be moderate to significant. Scant lochia rubra suggests that large clots are blocking the lochial flow. After delivery, vasomotor changes may cause a shaking chill. Thirst, fatigue, and a temperature of up to 100.4°F (38°
C) also are common at 24 hours postpartum.
Question 2 of 5
An 82-year-old woman who has Alzheimer's disease is admitted to the acute care unit. She frequently gets out of bed and wanders in the hall, unable to find her way back to her room. She even gets in the beds of other clients. What nursing action is most appropriate for this client?
Correct Answer: D
Rationale: A familiar picture on the door helps the Alzheimer's client recognize her room, reducing wandering safely. Restraints, roommate monitoring, or punishment are inappropriate or ineffective.
Question 3 of 5
Which interventions are appropriate when caring for a client with acute thrombophlebitis?
Correct Answer: D
Rationale:
To help treat thrombophlebitis, the nurse should prevent venostasis with measures such as applying warm soaks and elevating the client's legs. The client should remain on bed rest during the acute phase, after which the client may begin to walk while wearing antiembolism stockings. Treatment for thrombophlebitis may also include anticoagulants to prolong clotting time.
Question 4 of 5
A client has been admitted in septic shock. Her nursing care plan includes the diagnosis High Risk for Injury (related to clotting disorder). Based on this diagnosis, all the following are appropriate entries in the nursing care plan except:
Correct Answer: D
Rationale: Firm, direct pressure should be applied to venipuncture sites for 3-7 minutes before final dressing because of the clotting abnormality.
Question 5 of 5
Which of the following terms refers to soft-tissue injury caused by blunt force?
Correct Answer: A
Rationale: A contusion is a soft-tissue injury from blunt force, causing swelling and discoloration without breaking the skin. Strains and sprains involve ligaments or muscles, and dislocation affects joints. Physiological Adaptation