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

Questions 163

NCLEX-PN

NCLEX-PN Test Bank

NCLEX PN Exam Practice Test Questions

Extract:


Question 1 of 5

The nurse is caring for a client who has a C6 spinal cord injury. He complains of blurred vision and a severe headache. His blood pressure is 210/140. What action should the nurse take initially?

Correct Answer: A

Rationale: Symptoms and hypertension suggest autonomic dysreflexia, often triggered by bladder distention in spinal cord injury. Checking and relieving distention is the initial action.

Extract:

Laboratory reference ranges
Glucose (random)
71-200 mg/dL
(3.9–11.1 mmol/L)
Hematocrit
Male: 42%–52%
(0.42-0.52)

Female: 37%–47%
(0.37–0.47)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L)
Troponin T (cTnT)
<0.1 ng/mL
(<0.1 mcg/L)
B-type natriuretic peptide
<100 pg/mL
(<28.9 pmol/L)


Question 2 of 5

The nurse is reviewing laboratory data for a client admitted to the emergency department with chest pain. Which serum value requires immediate action by the nurse?

Correct Answer: D

Rationale: Elevated troponin T (0.7 ng/mL) indicates myocardial injury, requiring immediate action for possible myocardial infarction. Other values are less critical.

Extract:


Question 3 of 5

The nurse is planning care for a 6-month-old client admitted with bacterial meningitis. Which nursing action is the priority?

Correct Answer: D

Rationale: Prompt antibiotic therapy is critical to treat bacterial meningitis and prevent complications or death, making it the priority. A, B, and C are important but secondary; padding prevents injury, daily head circumference monitors for hydrocephalus, and a low-stimuli environment reduces seizure risk, but none address the infection directly.

Question 4 of 5

The oncoming nurse is receiving report on 4 clients. Which should be the priority assessment?

Correct Answer: A

Rationale: Elevated blood pressure (160/88 mm Hg) post-carotid endarterectomy risks hematoma or stroke, making it the priority. Other conditions are less urgent.

Question 5 of 5

The nurse is talking with a client with rheumatoid arthritis who has a new prescription for adalimumab. Which of the following statements by the client would require follow-up?

Correct Answer: D

Rationale: Adalimumab, an immunosuppressant, increases infection risk. Starting antibiotics for an active infection requires follow-up to ensure the infection is resolved before initiating adalimumab. The other statements are not concerning.

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