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

Questions 164

NCLEX-PN

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Extract:


Question 1 of 5

The nurse is reinforcing discharge teaching with the parent of a 6-year-old client who had a tonsillectomy 4 hours ago. The nurse should reinforce that it would be a priority to notify the health care provider if the client experiences

Correct Answer: C

Rationale: Frequent swallowing (
C) may indicate bleeding, a serious post-tonsillectomy complication requiring immediate reporting. Ear pain (
A), bad breath (
B), and low-grade fever (
D) are common and less urgent.

Question 2 of 5

During the evaluation phase for a client, the nurse should focus on

Correct Answer: B

Rationale: The client's status, progress toward goal achievement, and ongoing re-evaluation. Evaluation focuses on assessing progress and adjusting the care plan.

Question 3 of 5

A young adult is admitted with a possible head injury. The car in which he was riding hit a utility pole, and the client's head hit the windshield. Baseline vital signs are BP=112/74, P=80, and R=12. The nurse checks the client an hour after admission. Which finding(s) are significant and should be reported to the charge nurse or physician immediately? Select all that apply.

Correct Answer: C,D

Rationale: Slow respirations (8) and projectile vomiting suggest increased intracranial pressure, critical in head injury, requiring immediate reporting. BP, pulse, skin, and pupil response changes are less urgent.

Question 4 of 5

A client with active pulmonary tuberculosis is prescribed 4-drug therapy with ethambutol. The nurse reinforces previous teaching to notify the health care provider immediately if which adverse effect associated with ethambutol occurs?

Correct Answer: A

Rationale: Ethambutol can cause optic neuritis, leading to blurred vision (
A), a serious side effect requiring immediate reporting. Dark urine (
B), hearing loss (
C), and jaundice (
D) are associated with other TB drugs (e.g., rifampin, isoniazid).

Question 5 of 5

The nurse is caring for a client with anorexia nervosa. Which of the following findings would be consistent with the condition? Select all that apply.

Correct Answer: B,D,E,F

Rationale: Anorexia nervosa is characterized by severe weight loss and malnutrition, leading to specific clinical findings. Amenorrhea (
B) results from hormonal imbalances due to low body fat. Lanugo (
D), fine downy hair, develops as a compensatory mechanism for heat loss. Hypokalemia (E) occurs due to starvation or purging behaviors. A BMI of 16 kg/m² (F) indicates severe underweight status, consistent with anorexia. Heat intolerance (
A) is more typical of hyperthyroidism, and avoiding physical activity (
C) is incorrect as clients often engage in excessive exercise.

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