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

Questions 164

NCLEX-PN

NCLEX-PN Test Bank

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Question 1 of 5

The nurse is drawing blood from a client's peripheral vein for laboratory specimens. Which of the following are correct nursing actions? Select all that apply.

Correct Answer: A,C

Rationale: A tourniquet left on too long (
A) can cause hemoconcentration, so it should be removed after 1 minute. Pulsating blood (
C) indicates arterial puncture, requiring immediate needle withdrawal and pressure to prevent hematoma. Wet alcohol (
B) can cause hemolysis, and the ventral wrist (
D) is a risky site due to nerves and arteries. Vigorous shaking (E) damages blood cells, so gentle inversion is preferred.

Question 2 of 5

A 6-year-old child is receiving chemotherapy for leukemia. Which comment by the child indicates to the nurse that the child is adjusting well to the therapy?

Correct Answer: B

Rationale: Wearing a hat proudly suggests positive coping with hair loss from chemotherapy, indicating adjustment, unlike complaints of fatigue, bruising, or nausea.

Question 3 of 5

A client with a history of heart disease takes prophylactic aspirin daily. The nurse should monitor which of the following to prevent aspirin toxicity?

Correct Answer: D

Rationale: Serum albumin. When highly protein-bound drugs are administered to patients with low serum albumin (protein) levels, excess free (unbound) drug can cause exaggerated and dangerous effects.

Question 4 of 5

A client with gout who was started on allopurinol a week ago calls the health care provider’s office with several concerns. The nurse should recognize which report by the client as being significant and requiring immediate follow-up?

Correct Answer: C

Rationale: A rash (
C) may indicate a hypersensitivity reaction to allopurinol, potentially progressing to severe conditions like Stevens-Johnson syndrome, requiring immediate follow-up. Ibuprofen (
A), urination (
B), and nausea (
D) are less urgent.

Question 5 of 5

During the evaluation phase for a client, the nurse should focus on

Correct Answer: B

Rationale: The client's status, progress toward goal achievement, and ongoing re-evaluation. Evaluation focuses on assessing progress and adjusting the care plan.

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