NCLEX-PN
NCLEX-PN Practice Questions Quizlet Questions
Extract:
Question 1 of 5
The nurse is performing an assessment on a client who is cachectic and has developed an enterocutaneous fistula following surgery to relieve a small bowel obstruction. The client's total protein level is reported as 4.5 g/dl. Which of the following would the nurse anticipate?
Correct Answer: C
Rationale: The client is not absorbing nutrients adequately as evidenced by the cachexia and low protein levels. (A normal total serum protein level is 6.0-8.0 g/dl.) TPN will promote a positive nitrogen balance in this client who is unable to digest and absorb nutrients adequately.
Question 2 of 5
The nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions should the nurse prioritize?
Correct Answer: B
Rationale: Ensuring the endotracheal tube is secure prevents accidental extubation, maintaining airway and ventilation. ABGs (
A), sedatives (
C), and settings (
D) are important but secondary to airway security.
Extract:
While working on his motor bike, a 19-year-old sustains a puncture wound from a rusty metal. He presents himself to the ER of local hospital. The puncture wound is cleansed with hydrogen peroxide and a sterile dressing applied. The client confirmed that he is up-to-date with his tetanus immunization. Antibiotic was prescribed and administered and the client was sent home with instructions to return if there is any change in the wound area. Three days following the ER visit, the client is admitted to the hospital with a diagnosis of tetanus.
Question 3 of 5
Nursing care for client includes:
Correct Answer: A
Rationale: The slightest stimulation sets off a wave of very severe and painful muscle spasms involving the whole body. Admitting the client to a private room minimizes stimuli and reduces the risk of spasms.
Extract:
Question 4 of 5
The nurse is reviewing a client's pre-op lab values. Which of the following lab results warrants immediate attention?
Correct Answer: A
Rationale: A prothrombin time of 1 minute and 20 seconds is significantly prolonged, indicating a bleeding risk that requires immediate attention before surgery.
Question 5 of 5
The nurse is caring for a client after a motor vehicle accident. The client has a fractured tibia, and bone is noted protruding through the skin. Which action is of priority?
Correct Answer: B
Rationale: The client has an open fracture. The priority would be to cover the wound and prevent further contamination. Manual traction should not be attempted, so answer A is incorrect. Swelling usually occurs with a fracture, making answer C an incorrect option. Changing the client to the prone position would cause excessive movement and is inappropriate, so Answer D is incorrect.