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Questions 227

NCLEX-PN

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Extract:


Question 1 of 5

The nurse has taken the vital signs of a 95-year-old client: oral temperature = 98.6°F; pulse = 84 with a regular irregularity; respirations = 18; blood pressure = 140/86. Which nursing assessment(s) should be done first to obtain more data?

Correct Answer: A

Rationale: A regular irregularity in pulse suggests an arrhythmia, requiring an apical pulse for one minute to confirm and assess severity.

Extract:

A 14-year-old patient with a diagnosis of gonorrhea requested you not to tell her parents about the disease.


Question 2 of 5

How will you respond?

Correct Answer: B

Rationale: Confidentiality is maintained for minors in sensitive diagnoses like STIs, unless there's a legal requirement to disclose.

Extract:

Which of the following individuals is at greatest risk for experiencing cerebral vascular accident?


Question 3 of 5

A 50-year-old African-American male with history of hypertension.

Correct Answer: A

Rationale: This patient has multiple risk factors for CVA: African-American race, male gender, age, and hypertension.

Extract:


Question 4 of 5

Several passengers aboard an airliner suddenly become weak and suffer breathing difficulty. The diagnosis is likely to be:

Correct Answer: B

Rationale: Sudden, simultaneous symptoms in a group suggest chemical exposure, likely affecting the respiratory system. The other conditions are less likely to cause acute, collective symptoms. Safety and Infection Control

Extract:

The nurse assesses a patient's IV site and finds that it is red, hot, and tender to touch.


Question 5 of 5

The most appropriate first nursing action is:

Correct Answer: A

Rationale: Signs of phlebitis or infection require stopping the infusion and removing the IV to prevent further complications.

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