NCLEX-PN
Reduction of Risk Potential NCLEX PN Questions
Extract:
Question 1 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 2 of 5
Which of these actions is the primary nursing intervention designed to limit transmission of a client's Salmonella infection?
Correct Answer: A
Rationale: Gram-negative bacilli cause Salmonella infection, and lack of sanitation is the primary means of contamination. Thorough handwashing can prevent the spread of salmonella.
Question 3 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 4 of 5
The nurse sustains a needle puncture that requires HIV prophylaxis. Which of the following medication regimens should be used?
Correct Answer: B
Rationale: Unless there is drug resistance, the initial prophylaxis based on CDC recommendations is 2 NNRTIs.
Question 5 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.