NCLEX Questions, NCLEX Trainer Test 1 Questions, NCLEX-PN Questions, Nurselytic

Questions 157

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Question 1 of 5

The nurse has received her assignment for the day and is to care for the following clients. Which client should the nurse go to first?

Correct Answer: A

Rationale: The client with recent hematemesis is at risk for recurrent bleeding, requiring immediate assessment to ensure stability, prioritizing over stable surgical or presurgical clients.

Question 2 of 5

The nurse is caring for a client with a history of atrial fibrillation who is receiving digoxin (Lanoxin) 0.125 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?

Correct Answer: A

Rationale: Hypokalemia (potassium 3.0 mEq/L) increases the risk of digoxin toxicity, which can cause life-threatening arrhythmias in atrial fibrillation. Options B, C, and D are normal: sodium 140 mEq/L, magnesium 2.0 mEq/L, and calcium 9.0 mg/dL do not affect digoxin.

Question 3 of 5

When caring for a client with myasthenia gravis, an important nursing consideration would be to

Correct Answer: D

Rationale: client has increased muscle fatigue, needs more assistance toward end of day

Question 4 of 5

During the check up of a 2 month-old infant at a well baby clinic, the mother expresses concern to the nurse because a flat pink birthmark on the baby's forehead and eyelid has not gone away. What is an appropriate response by the nurse?

Correct Answer: C

Rationale: Telangiectatic nevi, salmon patch or stork bite birthmarks, are a normal variation and the facial nevi will generally disappear by ages 1 to 2 years.

Question 5 of 5

The nurse is caring for a client who is ordered to be on bed rest for a prolonged period of time. What should be included in the nursing care plan to prevent venous stasis?

Correct Answer: C

Rationale: Antiembolism stockings promote venous return, preventing stasis in bedridden clients. Breathing exercises, ROM, and turning address other complications but not venous stasis directly.

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