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

Questions 164

NCLEX-PN

NCLEX-PN Test Bank

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Extract:


Question 1 of 5

The nurse in the outpatient care facility is caring for a client with metastatic lung cancer who received chemotherapy 3 days ago. The client states, 'I have decided that I do not want to continue treatment.' Which of the following responses would be appropriate for the nurse to make?

Correct Answer: A

Rationale: Acknowledging the decision’s difficulty and notifying the provider respects autonomy and ensures follow-up. Other responses judge, guilt, or deflect the client’s choice.

Question 2 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 3 of 5

A 6-month old is brought to the ER by her mother. During the assessment, the nurse finds multiple bruises in different stages of healing and decreased range of motion of the right leg. X-ray confirms a fracture of the right femur. Which statement made by the mother would contribute to a diagnosis of child abuse?

Correct Answer: C

Rationale: The mother's inability to recall any injury event, combined with multiple bruises and a femur fracture, raises suspicion of child abuse due to inconsistent history.

Question 4 of 5

The nurse is caring for a client involved in a motor vehicle collision who had a chest tube inserted to evacuate a pneumothorax caused by fractured ribs. Where would the nurse observe an air leak?

Question Image

Correct Answer: A

Rationale: Bubbling in the water seal chamber indicates an air leak from the lung or tubing. The suction control chamber bubbles with suction, and the collection chamber collects fluid, not air.

Extract:

Laboratory reference ranges
INR
0.8-1.1


Question 5 of 5

The nurse receives report on 4 clients. Which of the following clients should the nurse see first?

Correct Answer: A

Rationale: Discomfort at an IV vancomycin site suggests possible infiltration or phlebitis, requiring immediate assessment to prevent tissue damage. INR of 1.9 is subtherapeutic but less urgent, itching/nausea are expected morphine side effects, and tubing changed 48 hours ago is within standard protocol.

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