NCLEX Questions, NCLEX Trainer Test 9 Questions, NCLEX-PN Questions, Nurselytic

Questions 155

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Extract:


Question 1 of 5

The nurse on postpartum is preparing four clients for discharge. It would be MOST important for the nurse to refer which of the following clients for homecare?

Correct Answer: D

Rationale: Burning on urination suggests a urinary tract infection, requiring homecare follow-up. Options A, B, and C are routine postpartum findings.

Question 2 of 5

The nurse is caring for a client with a history of seizures who is receiving phenytoin (Dilantin) 100 mg PO tid. Which of the following client statements would be of GREATest concern to the nurse?

Correct Answer: C

Rationale: A rash may indicate a hypersensitivity reaction to phenytoin, potentially progressing to severe conditions like Stevens-Johnson syndrome, requiring immediate evaluation. Options A, B, and D are less concerning: brushing teeth is routine, milk does not affect absorption, and drowsiness is a common side effect.

Extract:

A client is admitted to the emergency room in severe emotional distress. The client's respirations are 42/min, and the blood gases reveal a pH of 7.5 and a PaCO2 of 34.


Question 3 of 5

Initially the nurse should

Correct Answer: A

Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-because of hyperventilation, client is in alkalosis; having him rebreathe his own carbon dioxide will reverse his blood gas imbalance (2) does not address the problem (3) is not hypoxic (4) is done when a client feels faint

Extract:

The nurse is caring for clients on a psychiatric unit and is suddenly faced with multiple issues.


Question 4 of 5

Which of the following situations require the nurse's IMMEDIATE attention?

Correct Answer: B

Rationale: Strategy: 'Require IMMEDIATE intervention' indicates that you are looking for the least stable situation. (1) should remove to quiet area, decrease environmental stimuli (2) correct-could indicate impending suicide, requires immediate follow-up (3) potential suicide is more immediate concern (4) command hallucination, potential suicide takes priority

Extract:


Question 5 of 5

The nurse is caring for a client with a suspected pulmonary embolism.

Correct Answer: B

Rationale: A D-dimer blood Test is a sensitive screening tool for pulmonary embolism, detecting fibrin degradation products from a clot. Chest X-ray and ECG are non-specific, and ABG assesses oxygenation but not the diagnosis directly.

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