NCLEX Practice Questions PN
Question 1 of 5.
A client with borderline personality disorder says to the nurse, 'You're the only one I trust around here. The others don't know what they are doing and they don't care about anyone except themselves. I only want to talk with you.' What is the priority nursing action?
A. Assign different staff members to care for the client each day
B. Assign the client's stated preferred nurse to care for the client
C. Reassure the client that all staff members are competent in their jobs
D. Reinforce unit guidelines and appropriate boundaries with the client
Explanation: Reinforcing boundaries (D) addresses splitting behavior and maintains therapeutic relationships. Rotating staff (A), assigning the preferred nurse (B), or reassuring competence (C) may reinforce manipulation.
Question 2 of 5.
The nurse is giving home care to a 69-year-old client who has severe arthritis. Which comment made by the client would indicate to the nurse that the client is experiencing normal changes associated with the aging process?
A. I have such a hard time with the pain in my feet and knees.
B. I have had loose stools for the last few months.
C. My children say I keep my apartment too warm.
D. I have a hard time at night because the lights are all big and fuzzy.
Explanation: Feeling cold and preferring a warmer environment is a normal age-related change due to decreased thermoregulation. Pain, loose stools, and visual changes may indicate pathology requiring further investigation.
Question 3 of 5.
Diphenoxylate hydrochloride with atropine sulfate (Lomotil) is prescribed for a client. The nurse knows that the drug is prescribed for which of these problems the client has?
A. Diarrhea
B. Hypertension
C. Depression
D. Tachycardia
Explanation: Lomotil is an antidiarrheal, slowing intestinal motility to reduce diarrhea.
Question 4 of 5.
An adult is admitted with nausea, vomiting, and diarrhea. The client is receiving an IV of dextrose 5% in water with 40 mEq of KCl. The nurse knows the potassium is added to do which of the following?
A. Replace potassium lost because of vomiting and diarrhea
B. Replace potassium that the client is not getting from his diet
C. Stop the nausea
D. Stop the diarrhea
Explanation: Vomiting and diarrhea cause significant potassium loss, requiring IV potassium replacement to prevent hypokalemia.
Question 5 of 5.
An adult who has newly diagnosed angina has been prescribed sublingual nitroglycerin. What should be included in the nurse's teaching about the medication? Select all that apply.
A. Put the tablets under your tongue and let them dissolve.
B. Keep the tablets in a dark glass container.
C. You can take one tablet, and if you still have pain, you can take another tablet in 10 minutes.
D. Be sure to take nitroglycerin while you are standing up.
E. You may get a headache shortly after you take the medication,
F. If your tongue tingles spit out the tablet.
Explanation: Sublingual nitroglycerin is dissolved under the tongue, stored in dark glass to maintain potency, and may cause headaches as a side effect.
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