NCLEX Questions, NCLEX Trainer Test 7 Questions, NCLEX-PN Questions, Nurselytic

Questions 156

NCLEX-PN

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Question 1 of 5

The nurse is caring for a client who is receiving a blood transfusion. Which of the following findings would be of GREATest concern to the nurse?

Correct Answer: A

Rationale: A temperature of 100.4°F during a blood transfusion suggests a transfusion reaction, such as febrile non-hemolytic reaction, requiring immediate cessation of the transfusion. Options B, C, and D are normal: heart rate 90 bpm, respiratory rate 18 breaths/min, and blood pressure 120/80 mmHg do not indicate complications.

Question 2 of 5

The client says to the nurse, 'I don't see why I should live any longer.' How should the nurse respond initially?

Correct Answer: B

Rationale: Expressing a desire to not live suggests suicidal ideation; directly asking about suicide assesses risk and guides intervention. Exploring reasons, affirming life, or highlighting positives are secondary.

Question 3 of 5

The nurse is discussing dietary intake with an adolescent who has acne. The most appropriate statement for the nurse is

Correct Answer: A

Rationale: Eat a balanced diet for your age. There are no recommended additions and subtractions from the diet for acne management.

Question 4 of 5

A client taking isoniazid (INH) for tuberculosis asks the nurse about side effects of the medication. The client should be instructed to immediately report which of these?

Correct Answer: B

Rationale: Extremity tingling and numbness. Peripheral neuropathy is the most common side effect of INH and should be reported to the provider. It can be reversed.

Question 5 of 5

While a client is receiving TPN, it is MOST important for the nurse to monitor

Correct Answer: C

Rationale: TPN can cause hyperglycemia and electrolyte imbalances, making serum glucose and electrolyte monitoring critical. Options A, B, and D are less specific.

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