NCLEX Questions, NCLEX Trainer Test 2 Questions, NCLEX-PN Questions, Nurselytic

Questions 157

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Question 1 of 5

The nurse is screening an eight-month-old girl in a well-baby clinic. The nurse would be MOST concerned if the infant's mother made which of the following statements?

Correct Answer: A

Rationale: An eight-month-old should have doubled birth weight by 5–6 months; 'almost doubled' suggests growth delay, requiring evaluation. Options B, C, and D are normal behaviors.

Question 2 of 5

A client with asthma has low pitched wheezes present on the final half of exhalation. One hour later the client has high pitched wheezes extending throughout exhalation. This change in assessment indicates to the nurse that the client

Correct Answer: A

Rationale: Has increased airway obstruction. The higher pitched a sound is, the more narrow the airway.
Therefore, the obstruction has increased or worsened.

Question 3 of 5

The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?

Correct Answer: C

Rationale: Redness at the IV site suggests phlebitis or infiltration, which can lead to tissue damage or reduced vancomycin delivery, requiring immediate action. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 50 mL/hour indicate stability.

Question 4 of 5

The nurse recognizes which of these symptoms as characteristic of a panic attack?

Correct Answer: A

Rationale: panic disorders are characterized by recurrent, unpredictable attacks of intense apprehension or terror that can render a client unable to control a situation or to perform simple tasks; client can experience palpitations, chest pain, shortness of breath, a decrease in perceptual field, and a fear of 'losing it' or going crazy

Question 5 of 5

A client who is diagnosed with cystitis has been given a prescription for phenazopyridine (Pyridium). She asks the nurse why she has been given this medication. What should the nurse reply?

Correct Answer: C

Rationale: Phenazopyridine is a urinary tract anesthetic, relieving pain and burning during urination until antibiotics resolve cystitis. It's not an antibiotic, analgesic, or kidney protectant.

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