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

Questions 164

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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

In addition to standard precautions, a nurse should implement contact precautions for which client?

Correct Answer: A

Rationale: 60 year-old with herpes simplex. Clients who have herpes simplex infections must have contact precautions in addition to standard precautions because of the associated, potentially weeping, skin lesions. Contact precautions are used for clients who are infected by microorganisms that are transmitted by direct contact with the client, including hand or skin-to-skin contact.

Question 3 of 5

The nurse is preparing the sterile field and supplies for a wet-to-damp dressing change. Which of the following actions by the nurse would require follow-up?

Correct Answer: D

Rationale: Using saline from a bottle opened 30 hours ago risks contamination, as sterile solutions are typically discarded after 24 hours. Keeping the field in view and placing gauze appropriately maintain sterility.

Question 4 of 5

The nurse is assessing a client who had a thyroidectomy 12 hours ago and is reporting anxiety, tingling around the mouth, and muscle twitching in the hand. Which of the following actions would be a priority for the nurse to take?

Correct Answer: D

Rationale: Anxiety, tingling, and twitching suggest hypocalcemia from parathyroid damage during thyroidectomy, requiring urgent calcium level assessment. Edema, blood gases, and vocal quality are less urgent.

Question 5 of 5

A client has a serum glucose of 385 mg/dl. Which of these orders would the nurse question first?

Correct Answer: C

Rationale: Regular insulin is the only insulin that can be given by the intravenous route. Humulin N is not suitable for IV administration, making this the priority order to question.

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