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

Questions 163

NCLEX-PN

NCLEX-PN Test Bank

NCLEX PN Exam Practice Test Questions

Extract:


Question 1 of 5

The nurse has just completed a dressing change on an elderly client who is allowed bathroom privileges. Which action is most essential for the nurse to take before leaving the client's bedside?

Correct Answer: A

Rationale: Hand washing prevents infection transmission post-dressing change, a critical step. Lowering the bed, toileting, or pain assessment are secondary.

Question 2 of 5

A woman in labor calls the nurse to assist her in the bathroom. The nurse notices a large amount of clear fluid on the bed linens. The nurse knows that fetal monitoring must now assess for what complication?

Correct Answer: C

Rationale: When the membranes rupture, there is increased risk initially of cord prolapse. Fetal heart rate patterns may show variable decelerations, which require immediate nursing action to promote gas exchange.

Question 3 of 5

The nurse is caring for a client with a feeding tube that has become obstructed. Which intervention should the nurse implement first to unclog the tube?

Correct Answer: A

Rationale: Flushing with warm water is the first, safest step to unclog a feeding tube. Enzymes or other solutions are used if water fails, and small syringes may cause excessive pressure.

Question 4 of 5

The nurse has just completed a dressing change on an elderly client who is allowed bathroom privileges. Which action is most essential for the nurse to take before leaving the client's bedside?

Correct Answer: A

Rationale: Hand washing prevents infection transmission post-dressing change, a critical step. Lowering the bed, toileting, or pain assessment are secondary.

Question 5 of 5

A home health nurse visits a client with Alzheimer disease. The caregiver appears frustrated and reports that the client has been persistently restless and agitated. Which nursing action is the priority at this time?

Correct Answer: B

Rationale: Assessing for environmental triggers like noise is the priority, as it may contribute to agitation in Alzheimer's. Other actions are secondary.

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