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Questions 160

NCLEX-PN

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Extract:


Question 1 of 5

The nurse is caring for a client with a history of cirrhosis. Which laboratory value is most concerning?

Correct Answer: A

Rationale: Elevated ammonia levels in cirrhosis can lead to hepatic encephalopathy, a serious complication.

Question 2 of 5

Laboratory data for an adult client diagnosed with Pneumocystis carinii pneumonia indicate immunosuppression. Which is the most important in determining the client's susceptibility to this infection?

Correct Answer: D

Rationale: Pneumocystis carinii pneumonia is associated with immunosuppression, often linked to HIV, which is commonly transmitted through sexual practices.

Question 3 of 5

What are the priorities when planning the care of a 75-year-old hospitalized client who develops pneumonia? Select all that apply.

Correct Answer: B,E,F

Rationale: Maintaining oxygenation addresses hypoxia, a critical issue in pneumonia. Administering antibiotics promptly and obtaining blood cultures ensure timely treatment and accurate diagnosis.

Question 4 of 5

The physician orders enoxaparin (Lovenox) for a client who has been diagnosed with a blood clot. To prevent bruising, which actions by the nurse are most appropriate? Select all that apply.

Correct Answer: A,F

Rationale: Avoiding rubbing and applying gentle pressure minimize bruising at the injection site for enoxaparin.

Question 5 of 5

When a schizophrenic client claims to see demons in the room, how should the nurse document the finding?

Correct Answer: C

Rationale: Quoting the client's exact statement provides objective, accurate documentation of the hallucination.

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