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

Questions 164

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Question 1 of 5

The nurse is caring for a 75 year old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?

Correct Answer: A

Rationale: Extreme fatigue. Extreme fatigue and weakness are common, early signs of digitalis toxicity, which would be confirmed by a high blood serum level of digitalis.

Question 2 of 5

The nurse is observing the movements of a client receiving Thorazine (chlorpromazine). The client continually paces and rocks back and forth when sitting. The nurse recognizes that the client is experiencing:

Correct Answer: B

Rationale: Akathisia is characterized by restlessness, pacing, and rocking, which matches the client's symptoms. Answer A involves fixed upward gaze, Answer C involves muscle spasms, and Answer D involves slowed movements, all of which are incorrect.

Question 3 of 5

The nurse is reinforcing teaching with a client who had a total knee replacement and has a new prescription for enoxaparin. Which of the following information should the nurse reinforce?

Correct Answer: A

Rationale: Mild bruising or redness is an expected side effect of enoxaparin. Black stools indicate possible bleeding, and ibuprofen increases bleeding risk. Vitamin K restriction is not necessary.

Question 4 of 5

A hearing-impaired client is becoming withdrawn and depressed. He reports that even with a hearing aid, he is having increased difficulty hearing. Which suggestion is least likely to be helpful?

Correct Answer: A

Rationale: A hearing guide dog is less helpful for communication compared to social engagement, TDD, or closed-caption TV, which directly address hearing loss.

Question 5 of 5

The nurse is monitoring a 12-month-old diagnosed with intussusception. Which findings should the nurse expect? Select all that apply.

Correct Answer: B,D,E

Rationale: Intussusception is characterized by a sausage-shaped mass, paroxysmal pain with knee-drawing, and 'currant jelly' stools.

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