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Questions 163

NCLEX-PN

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Question 1 of 5

While sitting in the cafeteria, a nurse overhears two students discussing a client admitted for chemical detoxification. The nurse should:

Correct Answer: C

Rationale: Confronting the students addresses the breach of confidentiality directly and educates them. Reporting to the teacher or supervisor escalates unnecessarily, and ignoring the behavior allows the violation to persist.

Question 2 of 5

The nurse notes all of the following. Which should be attended to first?

Correct Answer: B

Rationale: A water spill near an ambulatory elderly client's bed poses an immediate fall risk, requiring prompt attention to ensure safety. Call bell access, pain, or water requests are less critical.

Question 3 of 5

The nurse is screening clients for those at risk for developing oral candidiasis. The nurse should recognize the client at highest risk for developing oral candidiasis is a client who

Correct Answer: C

Rationale: An HIV-positive client on long-term antibiotics is at highest risk for oral candidiasis due to immunosuppression and microbial imbalance. Albuterol use , sugary drinks , and low albumin are less significant risk factors.

Question 4 of 5

The nurse is reinforcing information about techniques to improve sleep habits with a client who experiences frequent insomnia. Which statement by the client requires further teaching?

Correct Answer: C

Rationale: Reading in bed associates the bed with wakefulness, requiring further teaching. Avoiding naps , cool temperature , and consistent sleep schedule promote sleep hygiene.

Question 5 of 5

Diltiazem (Cardizem) 90 mg qid is prescribed for an adult who has angina. Which statement by the client indicates a need for further instruction?

Correct Answer: C

Rationale: Diltiazem is not typically withheld based on heart rate alone unless specified; this indicates a need for clarification on administration instructions.

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