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

Questions 164

NCLEX-PN

NCLEX-PN Test Bank

NCLEX Practice Test PN Questions

Extract:


Question 1 of 5

The nurse is talking with a client who has urge incontinence and is receiving tolterodine. It would require immediate follow-up if the client reports

Correct Answer: B

Rationale: Not urinating for an entire workday suggests urinary retention, a serious side effect of tolterodine, requiring immediate evaluation to prevent bladder damage.

Question 2 of 5

The nurse in the outpatient clinic is talking with the spouse of a client with borderline personality disorder. The client's spouse states, 'My spouse self-inflicts lacerations on the arms to stop me from traveling for business. My spouse's actions are not a serious attempt at self-harm.' Which of the following responses would be appropriate for the nurse to make?

Correct Answer: B

Rationale: Self-inflicted lacerations, even if not suicidal, indicate significant distress in borderline personality disorder and require professional assessment to ensure safety and address underlying issues.

Question 3 of 5

A newborn had a bowel resection with temporary colostomy for Hirschsprung disease. The practical nurse should alert the supervising registered nurse about which postoperative finding?

Correct Answer: D

Rationale: A gray-tinged stoma suggests ischemia or poor perfusion, which is a critical finding requiring immediate reporting to assess for stoma viability.

Question 4 of 5

The nurse is walking through a crowded waiting room when the respiratory therapist approaches the nurse and asks, 'How is the client in room 312?' Which of the following responses would be most appropriate for the nurse to make?

Correct Answer: D

Rationale: Discussing client information in a crowded area risks breaching confidentiality. Moving to a private area ensures compliance with HIPAA and protects client privacy.

Question 5 of 5

A triage nurse has these 4 clients arrive in the emergency department within a 15 minute period. Which client should the triage nurse send back to be seen first?

Correct Answer: B

Rationale: A teenager who got a singed beard while camping. This client is in the greatest danger with a potential of respiratory distress, Any client with singed facial hair has been exposed to heat or fire in close range that could have caused damage to the interior of the lung. Note that the interior lining of the lung has no nerve fibers so the client will not be aware of swelling.

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