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

Questions 164

NCLEX-PN

NCLEX-PN Test Bank

NCLEX Practice Test PN Questions

Extract:


Question 1 of 5

The nurse is caring for a client after a motor vehicle accident. The client's injuries include 2 fractured ribs and a concussion. The nurse notes which findings as expected neurological changes for the client with a concussion? Select all that apply.

Correct Answer: A,C,D

Rationale: Amnesia (
A), brief loss of consciousness (
C), and headache (
D) are common symptoms of concussion due to temporary brain dysfunction.

Extract:

Laboratory reference ranges
Glucose (random)
71-200 mg/dL
(3.9–11.1 mmol/L)


Question 2 of 5

The nurse is caring for assigned clients. Which of the following clients should the nurse check first?

Correct Answer: C

Rationale: A blood glucose level of 55 mg/dL indicates severe hypoglycemia, a life-threatening condition requiring immediate intervention to prevent seizures or coma.

Extract:


Question 3 of 5

A nurse in the pediatric unit is preparing a 16-year-old for a surgical procedure and observes that the client has signed the informed consent for surgery. What should be the first action by the nurse?

Correct Answer: B

Rationale: Minors typically cannot provide legal consent unless they are emancipated or meet specific legal criteria. The nurse must first determine if the 16-year-old is legally able to sign the consent.

Question 4 of 5

The nurse is caring for assigned clients. The nurse should first check the client

Correct Answer: D

Rationale: Fever, redness, and pain around pin sites suggest a possible infection at the external fixation site, which is a priority due to the risk of osteomyelitis or systemic infection.

Question 5 of 5

The nurse is caring for a group of clients. Which finding requires immediate action by the nurse?

Correct Answer: A

Rationale: A peripheral IV in place for 84 hours increases the risk of infection and phlebitis. Guidelines recommend changing IV sites every 72-96 hours, so this requires immediate action to remove or replace the IV.

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