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

Questions 176

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Question 1 of 5

The nurse performs an assessment during a fluid exchange for the client who is 48 hours post-insertion of an abdominal Tenckhoff catheter for peritoneal dialysis. The nurse knows that the appearance of which of the following needs to be reported to the provider immediately?

Correct Answer: D

Rationale: Cloudy drainage is a sign of infection that can lead to peritonitis (inflammation of the peritoneum). The other options are expected side effects of peritoneal dialysis.

Question 2 of 5

A 70 year-old post-operative client has elevated serum BUN, HCT, Cl, and Na+. Creatinine and K+ are within normal limits. The nurse should perform additional assessments to confirm that an actual problem is:

Correct Answer: D

Rationale: Fluid volume deficit. In fluid volume deficit, serum BUN, Na+, and hematocrit may be elevated secondary to hemoconcentration.

Question 3 of 5

A nurse aide is taking care of a 2 year-old child with Wilm's tumor. The nurse aide asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN? The best response by the nurse would be which of these statements?

Correct Answer: A

Rationale: Manipulation of the abdomen can lead to dissemination of cancer cells to nearby and distant areas. Bathing and turning the child should be done carefully.

Question 4 of 5

The nurse is collecting data from a 10-year-old client during a routine physical examination. Which of the following actions should the nurse take? Select all that apply.

Correct Answer: A, C, D

Rationale: Using anatomical terminology (
A) promotes understanding. Explaining equipment and procedures (
C) reduces anxiety. Offering a gown and allowing underwear (
D) respects privacy. Adult examination sequences (
B) may not suit pediatric needs, and parents rating pain (E) may not accurately reflect the child's experience.

Question 5 of 5

The nurse administers subcutaneous insulin lispro at 0730 to a client as prescribed and the client consumes breakfast 30 minutes later. At what time is the client at highest risk for experiencing insulin-related hypoglycemia?

Correct Answer: B

Rationale: Insulin lispro peaks 1-2 hours after administration, so 1100 (
B), about 3.5 hours post-injection, is the highest risk time for hypoglycemia.

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