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Questions 164

NCLEX-PN

NCLEX-PN Test Bank

NCLEX PN Practice Questions Questions

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Question 1 of 5

The nurse is monitoring a 12-month-old diagnosed with intussusception. Which findings should the nurse expect? Select all that apply.

Correct Answer: B,D,E

Rationale: Intussusception is characterized by a sausage-shaped mass, paroxysmal pain with knee-drawing, and 'currant jelly' stools.

Question 2 of 5

In order to enhance a client's response to medication for chest pain from acute angina, the nurse should emphasize

Correct Answer: A

Rationale: Learning relaxation techniques. Reducing anxiety through relaxation enhances the effectiveness of pain medication for angina.

Question 3 of 5

Following a cholecystectomy, drainage from the client's T tube for the first 24 hours after the operation was 350 cc. What is the appropriate nursing action?

Correct Answer: D

Rationale: T-tube drainage of 300–500 mL in the first 24 hours post-cholecystectomy is expected as bile drains externally. Continuing to observe and measure is appropriate unless other signs of complications arise.

Question 4 of 5

The nurse on a medical surgical unit enters a room, finds a client unresponsive with no pulse, and starts 2 minutes of CPR. The nurse receives and attaches an automated external defibrillator, but no shock is advised. Which action should the nurse perform next?

Correct Answer: C

Rationale: If no shock is advised, CPR should resume immediately with chest compressions to restore circulation.

Question 5 of 5

During a situation of pain management, which statement is a priority to consider for the ethical guidelines of the nurse?

Correct Answer: A

Rationale: The client's self-report is the most important consideration. Pain is a complex phenomenon that is perceived differently by each individual. Pain is whatever the client says it is. The other statements are correct but not the most important considerations.

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