NCLEX Questions, NCLEX PN Prep Questions Questions, NCLEX-PN Questions, Nurselytic

Questions 164

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Question 1 of 5

The nurse is preparing to administer phenytoin oral suspension via nasogastric tube to a client with a seizure disorder. The client is receiving continuous enteral feedings. Which of the following actions should the nurse take?

Correct Answer: D

Rationale: Phenytoin binds to enteral feedings, reducing absorption. Holding feedings for 1 hour before and after administration ensures efficacy. Tube placement should be verified before, not after, administration. Blood pressure and pancreatic enzymes are unrelated.

Question 2 of 5

The unit secretary notifies the nurse that 4 clients called the nurses' station reporting pain. Which client should the nurse assess first?

Correct Answer: A

Rationale: Shoulder pain radiating down the arm post-amputation suggests a possible cardiac event (e.g., angina), a life-threatening condition requiring immediate assessment. Other pains, while severe, are more likely related to known conditions.

Question 3 of 5

The nurse is caring for a client with deep venous thrombosis of the lower extremity. Which of the following findings would the nurse expect to observe? Select all that apply.

Correct Answer: B,C,D

Rationale: DVT causes inflammation, leading to warmth, redness, pain, and edema in the affected extremity. Dry, shiny, hairless skin and cyanosis are more typical of arterial insufficiency, not DVT.

Question 4 of 5

The charge nurse is observing the nurse apply a condom catheter for a client who is uncircumcised. The charge nurse should intervene if the nurse

Correct Answer: B

Rationale: Retracting the foreskin before applying a condom catheter risks paraphimosis if not repositioned afterward, requiring intervention. Other actions are correct: attaching tubing, assessing skin, and leaving space prevent complications.

Question 5 of 5

A nurse receives report on a group of clients. Which client should the nurse assess first?

Correct Answer: B

Rationale: The toddler with circumoral cyanosis, distress, and inability to speak suggests a potential airway obstruction, a life-threatening emergency requiring immediate assessment. Other clients show less acute symptoms.

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