NCLEX-PN
NCLEX PN Prep Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a client who has no pulse and is experiencing the cardiac rhythm in the ECG strip shown below. The client has a do not attempt resuscitation directive. The health care provider (HCP) orders initiation of resuscitative measures. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: A client with a Do Not Attempt Resuscitation (DNAR) or Do Not Resuscitate (DNR) directive has legally chosen not to receive resuscitative measures, such as CPR or defibrillation, in the event of cardiac arrest. The nurse has an ethical and legal obligation to honor the client's advanced directive.
Question 2 of 5
The nurse in the outpatient clinic is speaking with a client diagnosed with cerebral arteriovenous malformation. Which statement would be a priority for the nurse to report to the health care provider?
Correct Answer: D
Rationale: A bad headache in a client with cerebral arteriovenous malformation may indicate increased intracranial pressure or bleeding, requiring urgent reporting. Other symptoms are less specific and less immediately critical.
Question 3 of 5
The nurse is caring for a client with deep venous thrombosis of the lower extremity. Which of the following findings would the nurse expect to observe? Select all that apply.
Correct Answer: B,C,D
Rationale: DVT causes inflammation, leading to warmth, redness, pain, and edema in the affected extremity. Dry, shiny, hairless skin and cyanosis are more typical of arterial insufficiency, not DVT.
Question 4 of 5
The nurse is caring for a bedridden client experiencing fecal incontinence. Which nursing intervention is the highest priority for this client?
Correct Answer: C
Rationale: Perianal skin care with barrier cream prevents skin breakdown, a common complication of fecal incontinence. Wound care consultation follows if breakdown occurs. Rectal tubes risk complications, and briefs may trap moisture, worsening irritation.
Question 5 of 5
The nurse understands that during the 'tension building' phase of a violent relationship, when the batterer makes unreasonable demands, the battered victim may experience feelings of
Correct Answer: B
Rationale: Helplessness. Victims feel depressed and helpless despite efforts to please the batterer.