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

Questions 164

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Extract:


Question 1 of 5

The parent of a child treated for injuries consistent with suspected child abuse has been told that a report will be made to Child Protective Services (CPS). The parent says angrily to the nurse, 'I don’t know why this is being reported. I told the health care provider (HCP) that it was an accident.' What is the best response by the nurse?

Correct Answer: C

Rationale: Explaining that reporting is legally mandated for child safety is factual and nonjudgmental. Deferring to CPS, questioning the parent, or doubting their explanation may escalate tension or avoid responsibility.

Question 2 of 5

Which nursing intervention is most critical during the administration of Acyclovir (Zovirax)?

Correct Answer: D

Rationale: Acyclovir can cause renal toxicity; encouraging fluids promotes renal perfusion and reduces risk of crystal formation in the kidneys.

Question 3 of 5

The home health nurse is caring for an 85-year-old client. It would require immediate follow-up if the client is reporting

Correct Answer: A

Rationale: A painful red area on the buttocks suggests a pressure injury, requiring immediate intervention to prevent worsening. Edema, vision loss, and memory issues are concerning but less urgent.

Question 4 of 5

A client with a history of asthma is admitted with severe shortness of breath and cyanosis. Which finding would indicate that the client is experiencing status asthmaticus?

Correct Answer: B

Rationale: Silent chest on auscultation indicates severe airway obstruction with minimal air movement, a hallmark of status asthmaticus, requiring immediate intervention.

Extract:

Exhibit 1
Medication administration record

Allergies: No known drug allergies

Medication Time
Insulin NPH: 75 units subcutaneously, twice daily 0800, 2000
Insulin lispro: sliding scale dosing, before meals and at bedtime 0800, 1130, 1730, 2100

Exhibit 2
Laboratory results and reference ranges

Sodium
136-145 mEq/L
(136-145 mmol/L) 141 mEq/L
(141 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L) 3.0 mEq/L
(3.0 mmol/L)
Glucose (fasting)
70-110 mg/dL
(3.9-6.1 mmol/L) 328 mg/dL
(18.2 mmol/L)





Question 5 of 5

The nurse is preparing to administer medications scheduled for 0800 to a client with type 1 diabetes mellitus. After reviewing the client's morning laboratory test results, which of the following actions would be a priority for the nurse to take?

Correct Answer: B

Rationale: Abnormal lab results (e.g., severe hypo/hyperglycemia) require provider notification to adjust treatment. Administering insulin, checking ketones, or rechecking glucose are secondary without specific lab values.

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