NCLEX-PN
Sensory NCLEX Questions Questions
Extract:
Question 1 of 5
An adult is being treated with phenytoin (Dilantin) for a seizure disorder. Five days after starting the medication, he tells the nurse that his urine is reddish-brown in color. What action should the nurse take?
Correct Answer: A
Rationale: Phenytoin commonly causes reddish-brown urine, a benign side effect, so informing the client is appropriate. Testing or reporting is unnecessary unless other symptoms suggest a problem.
Question 2 of 5
The nurse is teaching the client who has otitis media. To reduce the risk of recurrent otitis media, which vaccine should the nurse recommend?
Correct Answer: B
Rationale: Pneumococcal vaccine can reduce the risk of ear infections. Varicella, typhoid, and zoster vaccines prevent other conditions.
Question 3 of 5
The nurse completed teaching the client with a corneal abrasion about proper care of the injury. Which statements indicate that the client understood the teaching? Select all that apply.
Correct Answer: D,E
Rationale: Patching the eye for 24 hours reduces irritation and promotes healing. Avoiding rubbing prevents reinjury. Sudden absence of pain, keeping the eye uncovered, and short intervals between drops are incorrect.
Question 4 of 5
The nurse is caring for a client diagnosed with a cerebrovascular accident (CVA). Which assessment information should the nurse determine first when placing the client in the assigned room?
Correct Answer: A
Rationale: Homonymous hemianopia (loss of half the visual field) from a CVA affects safety and orientation, requiring immediate assessment. Bed preference, dietary setup, and PT consults are secondary.
Question 5 of 5
The nurse is caring for a client admitted with Guillain-Barré syndrome. On day three of hospitalization, his muscle weakness worsens, and he is no longer able to stand with support. He is also having difficulty swallowing and talking. The priority in his nursing care plan should be to prevent which of the following?
Correct Answer: A
Rationale: Difficulty swallowing increases the risk of aspiration pneumonia, making it the priority in Guillain-Barré syndrome.