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

Questions 176

NCLEX-PN

NCLEX-PN Test Bank

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Extract:


Question 1 of 5

The nurse reviews a prescription to insert an indwelling urinary catheter in a hospitalized client. Which rationale for indwelling urinary catheter insertion is most appropriate?

Correct Answer: A

Rationale: Acute urinary retention (
A) is a medical indication for catheterization. Confusion/incontinence (
B), fall risk (
C), and diuretics (
D) are not sufficient justifications.

Question 2 of 5

The nurse is caring for a client with Guillain-Barré syndrome after a recent gastrointestinal illness. Monitoring for which symptom is a nursing care priority in this client?

Correct Answer: C

Rationale: Inability to cough or lift the head (
C) indicates respiratory muscle weakness, a life-threatening complication in Guillain-Barré syndrome, making it the priority.

Question 3 of 5

The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm. Which finding requires intervention by the nurse?

Correct Answer: A

Rationale: Contraction duration of 95 seconds (
A) is too long and may reduce fetal oxygenation, requiring intervention. Frequency (
B), intensity (
C), and resting tone (
D) are within normal limits.

Question 4 of 5

The nurse is preparing to administer several medications through a client's feeding tube. None of the medications are extended release. Which of the following actions should the nurse implement? Select all that apply.

Correct Answer: B, C, D

Rationale: Crushing separately (
B) prevents interactions, liquid forms (
C) are preferred, and flushing (
D) ensures patency. Combining all medications (
A) or mixing with formula (E) can cause clogs or interactions.

Question 5 of 5

Which statement by a parent would alert the nurse to assess for iron deficiency anemia in a 14 month-old child?

Correct Answer: B

Rationale: My child doesn't like many fruits and vegetables, but she really loves her milk. Excessive milk intake can displace iron-rich foods, leading to iron deficiency anemia.

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