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

Questions 176

NCLEX-PN

NCLEX-PN Test Bank

NCLEX Practice Questions PN Questions

Extract:


Question 1 of 5

The nurse just administered routine immunizations to a healthy 15-month-old. What information should the nurse reinforce with the caregivers before they leave the clinic?

Correct Answer: C

Rationale: Redness and mild fever (
C) are common post-immunization reactions. A temperature above 100 F (
A) is too low a threshold for concern, fussiness for a week (
B) is excessive, and activity restriction (
D) is unnecessary.

Question 2 of 5

The nurse is providing home care for a client with heart failure and pulmonary edema. Which nursing diagnosis should have priority in planning care?

Correct Answer: B

Rationale: Activity intolerance related to oxygen supply and demand imbalance. This is the primary problem due to decreased cardiac output related to heart failure. There is a reduction of oxygen, leading to findings of dyspnea and fatigue.

Question 3 of 5

A client is being discharged after having a coronary artery bypass grafting x5. The client asks questions about the care of chest and leg incisions. Which instructions should the nurse reinforce? Select all that apply.

Correct Answer: A, B, D

Rationale: Reporting sensory changes (
A), signs of infection (
B), and washing gently (
D) promote healing. Soaking and peroxide (
C) can disrupt healing, and compression hose (E) are not routinely needed.

Question 4 of 5

A diabetic multigravida is scheduled for an amniocentesis at 32 weeks gestation to determine the L/S ratio and phosphatidyl glycerol level. The L/S ratio is 1:1 and the presence of phosphatidyl glycerol is noted. The nurse's assessment of this data is:

Correct Answer: C

Rationale: An L/S ratio of 1:1 and presence of phosphatidyl glycerol suggest immature lungs, indicating a high risk for respiratory distress syndrome, so C is correct. Answers A, B, and D are not directly related to these findings.

Question 5 of 5

The nurse is contributing to the plan of care for a client with pertussis. Which of the following interventions should the nurse suggest including in the client's plan of care? Select all that apply.

Correct Answer: A, B, E

Rationale: Monitoring respiratory effort (
A), droplet precautions (
B), and frequent fluids (E) manage pertussis symptoms and transmission. Negative pressure rooms (
C) are for airborne diseases, and cough suppressants (
D) may worsen mucus clearance.

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