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Questions 164

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PN NCLEX Practice Exam Questions

Extract:


Question 1 of 5

The nurse is caring for an older adult client who is confused and has a high risk for falls. The client is incontinent of urine and frequently attempts to get out of bed unassisted to use the restroom. Which nursing interventions are appropriate when caring for this client? Select all that apply.

Correct Answer: A,B,D

Rationale: Bed alarms (
A), hourly rounding (
B), and proximity to the nurses' station (
D) enhance safety and monitoring. Catheters (
C) increase infection risk and are not first-line, and raising all side rails (E) is a restraint and unsafe.

Question 2 of 5

A client who had a total knee replacement is to be discharged today. Which statement that the client makes indicates a need for further instruction?

Correct Answer: D

Rationale:
Total knee replacement typically allows partial weight-bearing with assistance post-surgery; complete non-weight-bearing suggests misunderstanding of mobility instructions.

Question 3 of 5

A client has many delusions. As the nurse helps the client prepare for breakfast the client comments 'Don't waste good food on me. I'm dying from this disease I have.' The appropriate response would be

Correct Answer: D

Rationale: This response does not challenge the client’s delusional system and thus forms an alliance by providing reassurance of desire to help the client.

Question 4 of 5

The practical nurse is reinforcing discharge teaching to a client seen for treatment of a second episode of acute gout. Which instructions should be included to prevent future exacerbations? Select all that apply.

Correct Answer: A,D,E

Rationale: Healthy weight (
A), hydration (
D), and limiting alcohol (E) reduce uric acid levels and gout risk. Diet sodas (
B) are not directly linked, and avoiding all protein (
C) is unnecessary.

Question 5 of 5

The day shift nurse provides handoff of care report to the oncoming night shift nurse. Which of the following statements by the nurse are appropriate to include in the report? Select all that apply.

Correct Answer: A,B,D,E

Rationale: Acetaminophen administration (
A), morphine effect (
B), irrigation replacement (
D), and ultrasound schedule (E) are relevant to care. Family behavior (
C) is subjective and inappropriate.

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