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Questions 164

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Question 1 of 5

The nurse is caring for a client with cholelithiasis and acute cholecystitis. The client suddenly vomits 250 mL of greenish-yellow emesis and reports severe right upper quadrant pain with radiation to the right shoulder. Which intervention would have the highest priority?

Correct Answer: B

Rationale: Acute cholecystitis with vomiting and severe pain suggests gallbladder inflammation or obstruction, requiring immediate cessation of oral intake (NPO status,
B) to prevent further stimulation and complications like perforation. Promethazine (
A) and pain medication (
D) are supportive but secondary. A nasogastric tube (
C) may be considered later but is not the priority.

Question 2 of 5

The nurse is caring for a client with schizophrenia who is experiencing visual hallucinations. The client states, 'There is a bad person standing in my room.' Which of the following responses would be most appropriate for the nurse to make?

Correct Answer: B

Rationale: When addressing hallucinations, the nurse should acknowledge the client’s fear while gently reinforcing reality. Response B validates the client’s emotions and clarifies that the nurse does not see the hallucination, maintaining trust without reinforcing the delusion. Labeling the hallucination as part of the illness (
A) may confuse or alienate the client. Promising medication will resolve it (
C) oversimplifies treatment, and distracting with games (
D) dismisses the client’s distress.

Question 3 of 5

A client with poorly controlled diabetes mellitus gives birth to a newborn at term gestation. When caring for the 2 hour-old newborn, which clinical finding requires the nurse to intervene?

Correct Answer: C

Rationale: Jitteriness (
C) in a newborn of a diabetic mother suggests hypoglycemia, a common complication due to maternal hyperglycemia causing fetal hyperinsulinism. Immediate intervention (e.g., glucose testing) is needed. Acrocyanosis (
A) is normal, heart rate 165/min while crying (
B) is within range, and respirations of 60/min (
D) are normal for a newborn.

Question 4 of 5

The nurse has reinforced teaching about formula preparation with the parent of a newborn. Which of the following statements by the parent would indicate a correct understanding of the teaching? Select all that apply.

Correct Answer: A,B,D

Rationale: Microwaving (
A) can cause uneven heating, risking burns, so it’s avoided. Washing the can top (
B) prevents contamination. Refrigerated formula must be discarded after 24 hours (
D) to prevent bacterial growth. Diluting less (
C) alters nutrition, and bottled water (E) may need boiling depending on safety, indicating incorrect understanding.

Question 5 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.

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