NCLEX Questions, NCLEX PN Practice Test Questions, NCLEX-PN Questions, Nurselytic

Questions 164

NCLEX-PN

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Question 1 of 5

The nurse is discussing dementia with the families of older adults. All of the following behaviors are reported. Which behavior is most suggestive of dementia?

Correct Answer: B

Rationale: Getting lost in a familiar area indicates significant spatial disorientation, a hallmark of dementia. Forgetting details, misplacing items, or color oversight are less specific.

Question 2 of 5

All nursing staff on the medical unit are responsible for implementing a new interdisciplinary fall prevention protocol. Which duties are appropriate for the licensed practical nurse to delegate to unlicensed assistive personnel to promote client safety? Select all that apply.

Correct Answer: B,C,D

Rationale: UAP can place commodes (
B), remind about slow position changes (
C), report condition changes (
D), and observe gait (E). Education (
A) requires nursing judgment, unsuitable for delegation.

Question 3 of 5

The nurse is preparing to administer IV cefazolin to a newly admitted client with cellulitis. The nurse notes the client is allergic to amoxicillin. Which of the following actions should the nurse take next?

Correct Answer: D

Rationale: Clients with an allergy to penicillin antibiotics (eg, amoxicillin) can experience a cross-sensitivity reaction
to cephalosporin antibiotics (eg, cefazolin) because the medication molecules are structurally similar. The
nurse should first obtain more information by asking about the type of reaction the client experienced because
allergic reactions can range from mild to severe (Option 4)
Cephalosporins can be safely administered to clients with a history of mild allergic reaction to penicillin (eg,
rash) but are contraindicated for clients with a history of anaphylaxis.

Question 4 of 5

A low-residue diet is ordered for an adult. The nurse knows that the client understands the diet when which menu is selected?

Correct Answer: B

Rationale: Gelatin, mashed potatoes, and sliced chicken are low-fiber, low-residue foods, suitable for the diet. Lettuce, corn, broccoli, and sesame seeds are high-fiber, increasing residue.

Question 5 of 5

The nurse is making a home visit to an adult who had a cataract extraction yesterday. Which observation indicates that the client needs more instruction?

Correct Answer: C

Rationale: Bending over post-cataract surgery increases intraocular pressure, risking complications; this indicates a need for further instruction on activity restrictions.

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