NCLEX-PN
Free NCLEX-PN Practice Questions Questions
Extract:
Question 1 of 5
The nurse is providing home care to a confused client. The client's family is using a restraint to keep the client from pulling out her indwelling catheter. What should the nurse plan to include when teaching the family?
Correct Answer: B
Rationale: Checking restrained extremities hourly ensures circulation and prevents injury. Scheduled removal, supervision-based removal, or nurse-only removal are less practical or safe.
Question 2 of 5
The physician has prescribed Protonix (pantoprazole) for a client with burns. The nurse recognizes that the medication will help prevent the development of:
Correct Answer: A
Rationale: Protonix (pantoprazole), a proton pump inhibitor, is prescribed to reduce gastric acid secretion and prevent stress-related mucosal damage, such as Curling's ulcer, which is common in burn patients due to stress and hypoperfusion. Answers B, C, and D are incorrect because Protonix does not directly address myoglobinuria, hyperkalemia, or paralytic ileus.
Question 3 of 5
A 76-year-old client is admitted to a long-term care facility with Alzheimer's-type dementia. The client has been wearing the same dirty clothes for several days. The nurse contacts the family and asks them to bring in clean clothing. Which intervention would best prevent further regression in the client's personal hygiene?
Correct Answer: A
Rationale: Clients with Alzheimer's-type dementia tend to fluctuate in their capabilities. Encouraging self-care to the extent possible helps increase the client's orientation and promotes a trusting relationship with the nurse. Making the client assume responsibility for physical care is unreasonable. Assigning a staff member to take over the client's physical care restricts the client's independence. Accepting the client's desire to go without bathing promotes poor hygiene.
Question 4 of 5
An adult is on long-term aspirin therapy and complains of tinnitus. Which interpretation by the nurse is accurate?
Correct Answer: D
Rationale: Tinnitus is a sign of aspirin toxicity (salicylism), indicating a minor overdose. It's not an expected effect, and GI bleed would present with other symptoms like melena.
Question 5 of 5
The nurse is assessing a client with chronic renal failure receiving peritoneal dialysis. Which of the following findings would require an intervention by the nurse?
Correct Answer: C
Rationale: Cloudy drainage from the catheter site indicates peritonitis, a serious complication requiring immediate intervention (e.g., antibiotics, physician notification). Abdominal fullness (
A) and bruising (
D) are common during early exchanges, and constipation (
B) is managed with diet or stool softeners.