NCLEX-PN
Reduction of Risk Potential NCLEX PN Questions
Question 1 of 5
The client with DM is receiving care in the home for a foot ulcer. The home health nurse documents the narrative note illustrated. Which problem should be the nurse's priority on the return visit?
Correct Answer: B
Rationale: Improper footwear increases the risk of injury or falls, which is critical for a diabetic client with reduced foot sensation and a healing ulcer.
Question 2 of 5
Which of these comments by a client would indicate the need for further teaching regarding safety with warfarin (Coumadin)?
Correct Answer: C
Rationale: Green leafy vegetables are high in vitamin K, which can counteract the anticoagulant effects of warfarin, requiring further teaching to ensure safe dietary practices.
Question 3 of 5
The nurse is performing a physical examination of a 3 month-old with a suspected heart murmur. Which assessment should be performed first?
Correct Answer: B
Rationale: Auscultate the mass. Auscultation of the chest to listen for a heart murmur is the first step in confirming the presence of a murmur and guides further assessment.
Question 4 of 5
The nurse is caring for a client who has just returned from the operating room after a cholecystectomy. Which of these findings requires immediate follow-up by the nurse?
Correct Answer: D
Rationale: An oxygen saturation of 88% indicates hypoxia, requiring immediate intervention to prevent respiratory compromise.
Question 5 of 5
A client with congestive heart failure is newly admitted to home health care. The nurse discovers that the client has not been following the prescribed diet. What would be the most appropriate nursing action?
Correct Answer: C
Rationale: Discuss diet with the client to learn the reasons for not following the diet. When new problems are identified, it is important for the nurse to collect accurate assessment data. Before reporting findings to the provider, it is best to have a complete understanding of the client's behavior and feelings as a basis for future teaching and intervention.