NCLEX Questions, NCLEX PN Prep Questions Questions, NCLEX-PN Questions, Nurselytic

Questions 164

NCLEX-PN

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Extract:


Question 1 of 5

Which nursing diagnosis is least likely to apply to the client admitted with a diagnosis of borderline personality disorder?

Correct Answer: D

Rationale: Borderline personality disorder is characterized by self-injury, identity issues, and low self-esteem, making A, B, and C relevant. Sensory-perceptual alteration is more associated with psychotic disorders, so D is least likely.

Question 2 of 5

A nurse is caring for a client who had a vaginal birth 2 hours ago. The nurse notes that the client's perineal pad is saturated with blood 20 minutes after placing a new pad. The client's fundus is boggy, palpable above the level of the umbilicus, and deviated to the right. Which intervention should the nurse perform first?

Correct Answer: C

Rationale: A boggy, deviated fundus and heavy bleeding suggest uterine atony and possible bladder distension preventing uterine contraction. Assisting to void relieves bladder pressure, promoting uterine involution. Oxytocin follows if bleeding persists.

Question 3 of 5

The nurse, assisting in applying a cast to a client with a broken arm, knows that the

Correct Answer: C

Rationale: Wet cast should be handled with the palms of hands. This prevents damage to the cast and ensures proper setting.

Extract:

Laboratory results
Glucose (fasting)
70-110 mg/dL
(3.9-6.1 mmol/L)
180 mg/dL
(10.0 mmol/L)


Question 4 of 5

The nurse is preparing to administer insulin aspart subcutaneously at 0700 to a client with type 1 diabetes mellitus. Which of following actions would be a priority for the nurse to take?

Correct Answer: B

Rationale: Insulin aspart is rapid-acting, peaking within 1-3 hours. Administering it at 0700 requires breakfast within 15 minutes to prevent hypoglycemia. Site selection is routine, rechecking glucose later is secondary, and teaching is not urgent.

Extract:


Question 5 of 5

The nurse is caring for a client at 15 weeks gestation who has hyperemesis gravidarum. Which of the following findings would be consistent with the condition?

Correct Answer: B

Rationale: Hyperemesis gravidarum causes severe vomiting, leading to ketosis (moderate to high urine ketones) from fat breakdown. Bradycardia, hyperkalemia, and hypertension are not typical; tachycardia and hypokalemia may occur.

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