NCLEX Questions, NCLEX PN Practice Tests Questions, NCLEX-PN Questions, Nurselytic

Questions 164

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Question 1 of 5

The nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most important measure to prevent skin breakdown?

Correct Answer: B

Rationale: Frequent turning. Frequent turning will prevent skin breakdown by relieving prolonged pressure on any one area.

Question 2 of 5

The nurse is caring for a client with Hodgkin's disease who will be receiving radiation therapy. The nurse recognizes that, as a result of the radiation therapy, the client is most likely to experience

Correct Answer: B

Rationale: nausea. Because the client with Hodgkin's disease is usually healthy when therapy begins, the nausea is especially troubling.

Question 3 of 5

The nurse is preparing the sterile field and supplies for a wet-to-damp dressing change. Which of the following actions by the nurse would require follow-up?

Correct Answer: D

Rationale: Using saline from a bottle opened 30 hours ago risks contamination, as sterile solutions are typically discarded after 24 hours. Keeping the field in view and placing gauze appropriately maintain sterility.

Question 4 of 5

The nurse in the outpatient clinic is talking with a client who was diagnosed with hypertension 6 months ago. The client's current blood pressure is 170/94 mm Hg. Which of the following questions would be most important for the nurse to ask?

Correct Answer: D

Rationale: A major disadvantage of long-term management of hypertension is poor adherence to the treatment plan. Blood pressure medications can have unpleasant adverse effects, including fatigue, dizziness, and erectile dysfunction. In addition, clients may stop taking the medications when they believe their blood pressure has returned to normal range or if medications are expensive. Abrupt discontinuation of prescribed antihypertensive medications can lead to hypertensive crisis, a life-threatening emergency characterized by severely elevated blood pressure (ie, systolic ≥180 mm Hg and/or diastolic ≥120 mm Hg).
To prevent complications (eg, end organ damage), the nurse should determine if the client has been taking the medications consistently (Option 4). There may be a need for a dosage change or addition of another medication.

Question 5 of 5

After receiving shift report, the nurse is assessing a client started on trimethoprim-sulfamethoxazole 2 days ago for treatment of a urinary tract infection. The client reports itching, and the nurse notices a diffuse maculopapular rash on the client's face. What should the nurse do first?

Correct Answer: C

Rationale: Examining the trunk and limbs determines the rash’s extent, guiding whether it’s a mild reaction or a severe one (e.g., Stevens-Johnson syndrome). Diphenhydramine, epinephrine, or allergy reassessment are secondary until the rash is fully assessed.

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