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Questions 227

NCLEX-PN

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Extract:


Question 1 of 5

Which client is at highest risk for developing a pressure ulcer?

Correct Answer: C

Rationale: 75 year-old with left sided paresthesia who is incontinent of urine and stool. Risk factors for pressure ulcers include: immobility, absence of sensation, decreased LOC, poor nutrition and hydration, skin moisture, incontinence, increased age, decreased immune response. This client has the greatest number of risk factors.

Question 2 of 5

Epoetin alfa (Epogen) is prescribed for a client who is on dialysis. When teaching the client about the drug, the nurse should plan to include which information about the drug?

Correct Answer: C

Rationale: Epoetin alfa replaces erythropoietin, deficient in kidney failure, to stimulate red blood cell production, correcting anemia. It does not affect urine production, waste removal, or athletic performance.

Extract:

A 35-year-old male has been an insulin-dependent diabetic for five years and now is unable to urinate.


Question 3 of 5

Which of the following would you most likely suspect?

Correct Answer: C

Rationale: Autonomic neuropathy can impair bladder function, causing urinary retention in long-term diabetes.

Extract:


Question 4 of 5

The nurse is caring for an adult who has ulcerative colitis. When planning care, the nurse knows that which nursing diagnosis is of highest priority?

Correct Answer: A

Rationale: Ulcerative colitis causes diarrhea, leading to fluid loss and dehydration, making deficient fluid volume the highest priority to prevent systemic complications like hypovolemia.

Question 5 of 5

A nurse is caring for a patient with diabetes mellitus who is experiencing hyperglycemia. Which of the following interventions should the nurse implement? (Select all that apply)

Correct Answer: A,B,D,E

Rationale: Insulin corrects hyperglycemia, sugar-free fluids prevent dehydration, monitoring tracks progress, and DKA assessment detects complications. Carbohydrate snacks worsen hyperglycemia.

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