The nurse is caring for a client with coronary artery diseas...

Following a motor vehicle accident, the client does not know where he is or what year it is and has short-term memory impairment. Which nursing action is most appropriate?

A. Offer several choices to the client.
B. Give simple directions to the client.
C. Give the client the details of the care.
D. Offer written instructions to the client.

Correct Answer: B

Rationale: Simple directions accommodate memory impairment and disorientation, enhancing comprehension and safety post-accident.

Laboratory reference ranges
Glucose (fasting)
70–110 mg/dL
(3.9–6.1 mmol/L)

The nurse is caring for a client who has acute pancreatitis. Which of the following findings is most concerning?

A. Serum glucose levels for the past 24 hours are ≥250 mg/dL (13.9 mmol/L)
B. Client is lying with knees drawn up to the abdomen to alleviate pain
C. Temperature is 102.2°F (39°C) with increasing abdominal pain
D. Five large, liquid stools are yellow and foul-smelling

Correct Answer: C

Rationale: Fever (102.2°F) with increasing abdominal pain suggests infection or abscess, a life-threatening complication of pancreatitis. Hyperglycemia, knee-flexed positioning, and diarrhea are concerning but less urgent.

After receiving shift report, the nurse is assessing a client started on trimethoprim-sulfamethoxazole 2 days ago for treatment of a urinary tract infection. The client reports itching, and the nurse notices a diffuse maculopapular rash on the client's face. What should the nurse do first?

A. Administer diphenhydramine
B. Administer injectable epinephrine
C. Examine the client's trunk and limbs
D. Reassess the client's allergy history

Correct Answer: C

Rationale: Examining the trunk and limbs determines the rash’s extent, guiding whether it’s a mild reaction or a severe one (e.g., Stevens-Johnson syndrome). Diphenhydramine, epinephrine, or allergy reassessment are secondary until the rash is fully assessed.

The nurse in the outpatient clinic is talking with a client who was diagnosed with hypertension 6 months ago. The client's current blood pressure is 170/94 mm Hg. Which of the following questions would be most important for the nurse to ask?

A. Are you feeling overwhelmed at home or work?
B. Can you describe your daily eating habits to me?
C. Do you smoke cigarettes or use tobacco products?
D. How often do you take your antihypertensive medications?

Correct Answer: D

Rationale: A major disadvantage of long-term management of hypertension is poor adherence to the treatment plan. Blood pressure medications can have unpleasant adverse effects, including fatigue, dizziness, and erectile dysfunction. In addition, clients may stop taking the medications when they believe their blood pressure has returned to normal range or if medications are expensive. Abrupt discontinuation of prescribed antihypertensive medications can lead to hypertensive crisis, a life-threatening emergency characterized by severely elevated blood pressure (ie, systolic ≥180 mm Hg and/or diastolic ≥120 mm Hg). To prevent complications (eg, end organ damage), the nurse should determine if the client has been taking the medications consistently (Option 4). There may be a need for a dosage change or addition of another medication.

Because an adult is scheduled for a cystoscopy, the nurse should plan to do which of the following immediately prior to the procedure?

A. Keep the client NPO for eight hours
B. Ask the client about claustrophobia
C. Ask the client about allergies to shellfish
D. Encourage fluids

Correct Answer: C

Rationale: Cystoscopy may involve iodine-based contrast; shellfish allergies suggest iodine sensitivity, requiring verification. NPO is not needed, claustrophobia is irrelevant, and fluids are not prioritized immediately before.

NCLEX PN Practice Tests

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