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

Questions 164

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Question 1 of 5

The nurse reports that a client with a Mantoux test has an induration of 10 mm. The nurse knows that the induration indicates:

Correct Answer: B

Rationale: A 10 mm induration indicates exposure to the tubercle bacillus, requiring further evaluation to determine active infection.

Question 2 of 5

The nurse is caring for a client with a history of headaches who has come to the clinic reporting a 'bad migraine.' The client was able to provide a full health history while waiting to be seen. Which finding is most concerning?

Correct Answer: B

Rationale: Flat affect and drowsiness in a migraine are atypical and may indicate a more serious condition like a neurological event, requiring urgent evaluation. Nausea and poor appetite are common in migraines, and the BP and respiratory rate are within normal limits.

Question 3 of 5

The nurse is preparing to instill dialysate for a client who is receiving peritoneal dialysis. It would be a priority for the nurse to

Correct Answer: C

Rationale: Sterile technique when spiking and attaching the dialysate bag prevents peritonitis, a life-threatening complication. Semi-Fowler positioning, recording output, and bag placement are important but secondary to infection prevention.

Question 4 of 5

The school nurse is called to the playground for an episode of mouth trauma. The nurse finds that the front tooth of a 9 year-old child has been avulsed ('knocked out'). After recovering the tooth, the initial response should be to

Correct Answer: A

Rationale: Rinse the tooth in water before placing it in the socket. Following avulsion of a permanent tooth, it is important to rinse the dirty tooth in water, saline solution or milk before re-implantation. If possible, replace the tooth in its socket within 30 minutes, avoiding contact with the root.

Question 5 of 5

The nurse is collecting data from a client with Bell’s palsy. Which of the following findings would the nurse expect to observe? Select all that apply.

Correct Answer: A,D,E

Rationale: Bell’s palsy causes unilateral facial weakness, leading to asymmetrical smiling, loss of forehead/brow movement, and reduced lacrimation. Frequent blinking is unlikely due to impaired muscle control, and shock-like pain is typical of trigeminal neuralgia.

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