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

Questions 164

NCLEX-PN

NCLEX-PN Test Bank

NCLEX Practice Test PN Questions

Extract:


Question 1 of 5

The parent of a 6-year-old calls the nurse and reports that the child was playing outside in the snow and the child's feet now appear red and swollen. What is the best response by the nurse?

Correct Answer: D

Rationale: Red and swollen feet suggest frostbite or cold injury. Immersing the feet in warm (not hot) water is the safest and most effective way to rewarm the tissue and prevent further damage.

Question 2 of 5

The nurse is documenting the assessment of a client's peripheral pulses. The nurse palpates the top portion of the client's feet and notes that the right pulse is full and strong, and the left pulse is diminished but still palpable. Which of the following would be correct documentation to include in the client's medical record?

Correct Answer: A

Rationale: The dorsalis pedis pulse is palpated on the top of the foot. A 3+ pulse is full and strong, and 1+ is diminished but palpable, accurately reflecting the findings.

Question 3 of 5

The nurse assesses a child with intussusception. Which assessment findings require priority intervention?

Correct Answer: A

Rationale: Abdominal rigidity with guarding suggests peritonitis or perforation, critical complications of intussusception requiring immediate surgical intervention.

Question 4 of 5

A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to

Correct Answer: B

Rationale: A physical therapist can assist a client to improve the fine motor skills needed to prepare an insulin injection.

Question 5 of 5

The nurse is caring for a client with cirrhosis who has ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort. Which of the following actions should the nurse take? Select all that apply.

Correct Answer: C,D,E

Rationale: Semi-Fowler position helps alleviate shortness of breath by reducing pressure on the diaphragm. An alternating air pressure mattress reduces the risk of pressure injuries due to immobility. Music can help reduce discomfort and anxiety, providing a non-pharmacological distraction.

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