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

Questions 164

NCLEX-PN

NCLEX-PN Test Bank

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Question 1 of 5

The nurse is assessing a client who had a left arm cast applied four hours ago. Which finding indicates that the client may have circulatory impairment?

Correct Answer: B

Rationale: Cold fingers suggest impaired circulation in the casted arm, indicating potential compartment syndrome or vascular compromise, requiring immediate evaluation. Normal blanching, fracture pain, or immobility are less specific.

Question 2 of 5

A client is admitted with a head injury. Which vital sign assessment is most indicative of increased intracranial pressure?

Correct Answer: B

Rationale: Vital signs correlating with increased intracranial pressure are an elevated BP with a widening pulse pressure, a slow pulse rate, and an elevated temperature with involvement of the hypothalamus. Answer C relates to hypovolemia, so it is incorrect. Answers A and D do not relate to increased intracranial pressure and are therefore incorrect.

Question 3 of 5

Which incidence should be documented on an unusual incident report?

Correct Answer: D

Rationale: A fall is an unusual incident requiring documentation due to potential injury and liability. Leaving AMA, transfusion fever, or upset stomach are notable but less likely to require an incident report.

Question 4 of 5

All of the following tasks need to be done. Which one can the LPN/LVN safely delegate to the certified nursing assistant (CNA)?

Correct Answer: B

Rationale: Routine vital signs are within a CNA's scope of practice. Tube feeding, specialized blood pressure monitoring, and wound care require nursing judgment and skills.

Question 5 of 5

Which of the following activities demonstrate safe client handling practices? Select all that apply.

Correct Answer: B,C,D

Rationale: Using a gait belt, two people for a comatose client, and three for a heavy client ensure safety and prevent injury. One person for a recent hip replacement risks falls or dislocation due to limited mobility.

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