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

Questions 164

NCLEX-PN

NCLEX-PN Test Bank

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Extract:


Question 1 of 5

The nurse is monitoring a client during the dwell time of a peritoneal dialysis cycle. Which of the following findings would require immediate follow-up?

Correct Answer: B

Rationale: Crackles suggest fluid overload, a serious dialysis complication. Nausea , mild edema , and normal BP/HR are less urgent.

Question 2 of 5

The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action?

Correct Answer: A

Rationale: Normal ICP is less than 15. 66 is a high reading, and the RN and the physician should be notified. Answer B would be the action if the reading was normal, so it is incorrect. Answers C and D would not be appropriate actions, so they are wrong.

Question 3 of 5

A client is admitted with a lower urinary tract infection from an obstructing ureteral stone. Which tasks can the nurse delegate to the experienced unlicensed assistive personnel? Select all that apply.

Correct Answer: B,C

Rationale: Turning and measuring output are within UAP scope. Collecting specimens , monitoring characteristics , and teaching require nursing judgment.

Question 4 of 5

The nurse is reinforcing discharge instructions to a client who has had coronary artery bypass grafting. Which teachings are correct? Select all that apply.

Correct Answer: B,C,D

Rationale: Reporting infection signs , weight restrictions , and daily showers are correct. Sexual activity can resume earlier if stable, and lotion is not routine.

Question 5 of 5

A client is prescribed warfarin sodium (Coumadin) to be continued at home. Which focus is critical to be included in the nurse's discharge instruction?

Correct Answer: B

Rationale: Report any nose or gum bleeds. The client should notify the health care provider if blood is noted in stools or urine, or any other signs of bleeding occur.

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