NCLEX Questions, NCLEX PN Practice Tests Questions, NCLEX-PN Questions, Nurselytic

Questions 164

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Question 1 of 5

The nurse cares for a confused client who continues to pull at the intravenous (IV) catheter on the left forearm despite frequent instructions not to do so. What is the nurse's next action?

Correct Answer: D

Rationale: An arm board on the left arm stabilizes the IV site, reducing pulling without restraining the client, aligning with least-restrictive interventions. Mitts or restraints on the right side do not protect the left-sided IV.

Question 2 of 5

The nurse is discussing activities to promote language development with the parent of a 2-year-old. Which statement by the parent requires follow-up?

Correct Answer: D

Rationale: Enrolling a 2-year-old in soccer is premature, as it does not directly promote language development and is not age-appropriate. Reading rhyming books and facilitating peer play with toys support language skills.

Question 3 of 5

The nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most important measure to prevent skin breakdown?

Correct Answer: B

Rationale: Frequent turning. Frequent turning will prevent skin breakdown by relieving prolonged pressure on any one area.

Question 4 of 5

The nurse is caring for a client who had a total abdominal hysterectomy 2 days ago. The client reports hearing music coming from the television, which is turned off. Which of the following actions should the nurse take first?

Correct Answer: B

Rationale: Checking the medication record identifies potential causes of hallucinations, such as opioids or anesthetics. Timing, vital signs, and TV checks are secondary to ruling out medication effects.

Question 5 of 5

A client comes into the community health center upset and crying stating 'I will die of cancer now that I have this disease.' And then the client hands the nurse a paper with one word written on it: 'Pheochromocytoma.' Which response should the nurse state initially?

Correct Answer: A

Rationale: Pheochromocytomas usually aren't cancerous (malignant). But they may be associated with cancerous tumors in other parts of the body, providing reassurance and accurate information to alleviate the client's fear.

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