NCLEX Questions, NCLEX Trainer Test 2 Questions, NCLEX-PN Questions, Nurselytic

Questions 157

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Question 1 of 5

The nurse is caring for a client with a pressure ulcer.

Correct Answer: A

Rationale: A hydrocolloid dressing maintains a moist environment, promoting healing in a stage III pressure ulcer. Hydrogen peroxide is cytotoxic, repositioning every 2 hours is standard, and antibiotics are only used for infection.

Question 2 of 5

The nurse is developing a care plan for a client with severe anxiety. An appropriate outcome for the client is that within 4 days the client should:

Correct Answer: B

Rationale: Outcome criteria need to be specific, measurable, and realistic. Talking for 10 minutes meets all of these conditions.

Question 3 of 5

The client with cancer has an order for Adriamycin. Which of the following untoward effects is of particular concern to the nurse?

Correct Answer: C

Rationale: Adriamycin (doxorubicin) is cardiotoxic, and dysrhythmias are a serious concern. Alopecia, fatigue, and nausea are common but less life-threatening.

Question 4 of 5

The nurse is caring for a client with a suspected stroke. Which of the following actions should the nurse perform FIRST?

Correct Answer: C

Rationale: Hypoglycemia can mimic stroke symptoms; checking blood glucose is the first step to rule out treatable causes. Options A, B, and D are secondary.

Question 5 of 5

The greatest threat during the immediate post-burn period results from burn shock. Which of the following statements best describes why burn shock occurs?

Correct Answer: A

Rationale: Burn shock occurs due to histamine release causing vasodilation and increased capillary permeability, leading to fluid loss from the vascular to interstitial space.

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