NCLEX-PN Assessment Questions with

NCLEX-PN Assessment Questions with Complete and Verified Solutions

The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made? ✔✔1. "I will use a straw for drinking."

• "I will drive only during the daytime."
• "I will use caution because the device alters balance."
• "I will wash the skin daily under the lamb's-wool liner of the vest."

The nurse is caring for a client in preterm labor who is receiving terbutaline sulfate to stop uterine activity. During this medication therapy, the nurse implements nursing interventions to monitor which specific body organs that can be affected by this medication? ✔✔1. Heart and lungs 2.Kidneys and lungs

• Heart and kidneys
• Lungs and gastrointestinal tract

The client with squamous cell carcinoma of the larynx is receiving bleomycin intravenously. The nurse caring for the client anticipates that which diagnostic study will be prescribed? ✔✔1.Echocardiography

• Electrocardiography
• Cervical radiography
• Pulmonary function studies

The nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of heart failure (HF). The nurse should observe for which early sign of HF? ✔✔1. Pallor

• Cough
• Tachycardia
• Slow and shallow breathing

The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family?Select all that apply. ✔✔1. Discourage reminiscing.

• Make the decisions for the family.
• Encourage expression of feelings, concerns, and fears.
• Explain everything that is happening to all family members.
• Touch and hold the client's or family member's hand if appropriate.
• Be honest and let the client and family know that they will not be abandoned by the nurse.

The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period was October 20, 2016. Using Nägele's rule, the nurse determines the estimated date of birth is which? ✔✔1. July 12, 2017

• July 27, 2017*
• August 12, 2017
• August 27, 2017

Oxybutynin chloride (Ditropan XL) is prescribed for a client with neurogenic bladder. Which sign would indicate a possible toxic effect related to this medication? ✔✔1. Pallor

• Drowsiness
• Bradycardia
• Restlessness

A client diagnosed with angina pectoris returns to the nursing unit after experiencing an angioplasty. The nurse reinforces instructions to the client regarding the procedure and home care measures. Which statement by the client indicates an understanding of the instructions? ✔✔1. "I am considering cutting my workload."

• "I need to cut down on cigarette smoking."*
• "I am so relieved that my heart is repaired."

4."I need to adhere to my dietary restrictions."

The nurse notes that the 4-hour postpartum client has cool, clammy skin and that she is restless and excessively thirsty. The nurse immediately notifies the registered nurse and then performs which action? ✔✔1. Checks the vital signs 2.Begins fundal massage

• Encourages ambulation
• Encourages the client to drink fluids

The nurse is assigned to care for a client with a diagnosis of detached retina. Which finding would indicate that bleeding has occurred as a result of retinal detachment? ✔✔1. Total loss of vision

• A reddened conjunctiva
• A sudden sharp pain in the eye
• Complaints of a burst of black spots or floaters

The nurse is caring for a child with a diagnosis of Kawasaki disease. The mother of the child asks the nurse about the disorder. Which statement most accurately describes Kawasaki disease? ✔✔1.It is an acquired cell-mediated immunodeficiency disorder.

• It is a chronic multisystem autoimmune disease characterized by the inflammation of connective

tissue.

• It is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of

unknown cause.

• It is an inflammatory autoimmune disease that affects the connective tissue of the heart, joints,

and subcutaneous tissues.

The nurse is assigned to care for a child with a spica cast. Which action should be avoided when caring for the child? ✔✔1. Observing for nonverbal signs of pain

• Using pillows to elevate the head and shoulders
• Checking neurovascular status of the extremities
• Placing the child on a stretcher and bringing the child to the playroom

A child is brought to the emergency department, and a fracture of the left lower arm is suspected.The mother states that the child was rollerblading and attempted to break a fall with an outstretched

arm. The child receives diagnostic x-rays, from which it has been determined that a fracture is present. A plaster of Paris cast is applied to the arm, and the nurse reinforces instructions to the mother regarding cast care at home. Which instructions should the nurse provide to the mother?✔✔1. "The cast should be dry in about 6 hours."

• "The cast is water resistant, so the child is able to take a bath or a shower."
• "The cast needs to be kept dry because, when wet, it will begin to disintegrate." *
• "The cast will not mold to the body and should heal the fracture in no time at all."

The nurse is caring for a client who is scheduled for electroconvulsive therapy (ECT). The nurse notes that an informed consent has not been obtained for the procedure. On review of the record, the nurse notes that the admission was an involuntary hospitalization. Based on this information, which determination does the nurse make regarding consent? ✔✔1. An informed consent does not need to be obtained.

• The health care provider will obtain the informed consent.
• An informed consent should be obtained from the family.
• An informed consent needs to be obtained from the client. *

The nurse is preparing a 2-year-old child with suspected nephrotic syndrome for a renal biopsy to confirm the diagnosis. The mother asks the nurse, "Will my child ever look thin again?" The nurse should respond by giving which statement? ✔✔1. "Do you feel guilty about your child's weight gain?"

• "In most cases, medication and diet will control fluid retention." **
• "Wearing loose-fitting clothing should help conceal the extra weight."
• "When children are little, it's expected that they'll look a little chubby."

A client who has undergone cataract removal without an intraocular lens implant is visibly upset because his vision is still blurry. Which action should the nurse perform to provide realistic reassurance to this client? ✔✔1. Explain that vision will improve with adjustment to aphakic lenses.

• Reassure the client that bright color contrasts in the environment will help.
• Tell the client that there are many resources available for those with impaired vision.