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

Questions 164

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Question 1 of 5

The nurse is feeding a 3-month-old client with tetralogy of Fallot. During the feeding, the client becomes cyanotic and has difficulty breathing. Which action should the nurse take first?

Correct Answer: D

Rationale: The knee-chest position increases systemic vascular resistance and reduces right-to-left shunting in tetralogy of Fallot, immediately improving oxygenation during a tet spell.

Question 2 of 5

The nurse is caring for assigned clients. The nurse should first check the client

Correct Answer: D

Rationale: Fever, redness, and pain around pin sites suggest a possible infection at the external fixation site, which is a priority due to the risk of osteomyelitis or systemic infection.

Question 3 of 5

During the admission bath, the nurse notes a region of impaired skin under a large sacral dressing. Which of the following actions by the nurse are appropriate? Select all that apply.

Question Image

Correct Answer: A,C,D,E

Rationale: A nutrient-rich diet (
A) supports wound healing. Cleansing with saline (
C) prevents infection. A hydrophilic dressing (
D) promotes a moist healing environment. Frequent repositioning (E) reduces pressure on the impaired skin.

Question 4 of 5

The nurse has an order to administer ophthalmic drops and ophthalmic ointment to a client being treated for conjunctivitis. The nurse should:

Correct Answer: B

Rationale: Applying drops first, then waiting 5 minutes before ointment, ensures proper absorption of both. Ointment first would block drops, and combining forms is unnecessary.

Question 5 of 5

The nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first?

Correct Answer: D

Rationale: Smoking cessation. Stopping smoking is the priority for clients at risk for cardiac disease, because of its effects of reducing oxygenation and constricting blood vessels.

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