NCLEX Questions, NCLEX Trainer Test 10 Questions, NCLEX-PN Questions, Nurselytic

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Question 1 of 5

The nurse is caring for a client with a history of congestive heart failure.

Correct Answer: A

Rationale: Daily weight monitoring detects fluid retention early, a key indicator of worsening heart failure. Extra diuretics require medical orders, high-sodium diets worsen fluid retention, and exercise is encouraged within limits.

Question 2 of 5

The nurse is preparing to administer insulin to a client with type I diabetes.

Correct Answer: B

Rationale: Checking the client’s blood glucose level is the first step to ensure the insulin dose is appropriate, preventing hypo- or hyperglycemia. Verifying the dose, cleansing the site, and rotating sites are important but follow glucose confirmation.

Question 3 of 5

The nurse assesses a prolonged deceleration of the fetal heart rate while the client is receiving oxytocin IV to stimulate labor. The priority nursing intervention would be to

Correct Answer: A

Rationale: will decrease contractions and thus possibly remove uterine pressure to the fetus, which is possibly cause of deceleration

Question 4 of 5

A five-year-old is scheduled for a lumbar puncture (LP). Which of the following nursing actions would BEST prepare the child for the procedure?

Correct Answer: C

Rationale: excellent method to use with a child because it incorporates actually 'feeling' many aspects of the procedure as they are explained

Question 5 of 5

A client reports that he has been vomiting for three days, has a low-grade temperature, and feels lethargic. Which Ivanof the following nursing actions is MOST appropriate in evaluating for fluid volume deficit?

Correct Answer: B

Rationale: daily weight is the best way to evaluate for fluid volume deficit

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