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

Questions 164

NCLEX-PN

NCLEX-PN Test Bank

NCLEX PN Practice Test Questions

Extract:


Question 1 of 5

The nurse is caring for a client who received albuterol 30 minutes ago for an acute exacerbation of asthma. It would indicate that the medication has been effective if the client experiences a decreased

Correct Answer: A

Rationale: Albuterol, a bronchodilator, relieves bronchospasm in asthma, reducing airway resistance. Decreased use of accessory muscles (
A) indicates improved breathing and oxygenation, a direct sign of albuterol's effectiveness. Changes in blood pressure (
B), anxiety (
C), or heart rate (
D) are not primary indicators of albuterol's effect, as they may be influenced by other factors like the stress of the attack or concurrent medications.

Question 2 of 5

The nurse is caring for a client with hepatic encephalopathy who is receiving lactulose. Which of the following findings would indicate that the medication has been effective?

Correct Answer: A

Rationale: Lactulose is used in hepatic encephalopathy to reduce ammonia levels by promoting its excretion through the stool. Improved mental status (
A) indicates reduced ammonia toxicity, directly reflecting the medication's therapeutic effect. Looser stools (
B) and reduced abdominal distension (
C) are expected effects of lactulose but are secondary to the primary goal of ammonia reduction. Increased serum potassium (
D) is incorrect, as lactulose does not directly affect potassium levels.

Extract:

Laboratory results
Hematocrit
Male: 42%–52%
(0.42-0.52)

Female: 37%–47%
(0.37–0.47) 30%
(0.30)
Activated PTT
Baseline: 30–40 sec 110 sec
Platelets
150,000–400,000/mm3
(150–400 × 109/L) 80,000/mm3
(80 x 109/L)
PT
11–12.5 sec 11 sec


Question 3 of 5

The nurse is reinforcing teaching for a client who is prescribed acyclovir for genital herpes. Which statement should be included by the nurse?

Correct Answer: A

Rationale: Heparin is an anticoagulant that helps prevent further clot formation. It is titrated based on activated partial
thromboplastin time (aPTT). The therapeutic aPTT target is 1.5-2.0 times the normal reference range of 30-40
seconds. A aPTT value >100 seconds would be considered critical and could result in life-threatening side
effects. Common sentinel events that result from heparin drips include epistaxis, hematuria, and gastrointestina
bleeds (Option 1).
(Option 2) A normal hematocrit for a female is 37%-47% (0.37-0.47). In a client with a history of chronic
anemia, a hematocrit of 30% (0.30) may be an expected finding.
(Option 3) A normal platelet count is 150,000-400,000/mm* (150-400 x 10%L). In a client with a history of liver
cirrhosis, a platelet count of 80,000/mmª (80 x 10%/L) would be anticipated. An episode of bleeding rarely occurs
with a platelet count >50,000 mm* (50 x 10%/L).
(Option 4) A normal prothrombin time is 11-12.5 seconds, and so a level of 11 seconds would not be
concerning.

Extract:


Question 4 of 5

The nurse enters the room of a client who had major abdominal surgery 1 week ago and notes dehiscence and evisceration of the surgical incision. The nurse should immediately place the client in the

Correct Answer: A

Rationale: Low Fowler with knees bent (
A) reduces abdominal tension, preventing further evisceration while awaiting surgical intervention. Prone (
B), supine flat (
C), or side-lying (
D) increase strain or risk organ protrusion.

Question 5 of 5

The nurse is providing dietary teaching for an elderly client living on fixed income. Which food choices would provide the client with needed nutrients and be cost effective?

Correct Answer: B

Rationale: Spinach, dried beans, and tomatoes are nutrient-rich (vitamins, protein, fiber) and cost-effective. Bacon , ham , and beef/cheese/milk are more expensive and less balanced.

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