NCLEX Questions, NCLEX Trainer Test 3 Questions, NCLEX-PN Questions, Nurselytic

Questions 157

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Question 1 of 5

A 15-year old is admitted following a motor vehicle accident. Examination reveals that the client has a closed head injury, a linear fracture of the temporal bone, a fracture of the mandible, and multiple abrasions. Upon admission, he is very drowsy. Which of the following orders would not be a part of the patient's care?

Correct Answer: D

Rationale: Demerol is contraindicated in head injuries due to its potential to mask neurological changes and increase intracranial pressure.

Question 2 of 5

The nurse is caring for a client with a history of heart failure who is receiving digoxin (Lanoxin) 0.25 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?

Correct Answer: B

Rationale: Nausea and loss of appetite are signs of digoxin toxicity, a serious complication requiring immediate evaluation, especially in heart failure. Options A, C, and D are less concerning: fatigue and headaches are nonspecific, and taking digoxin with food is acceptable.

Question 3 of 5

The nurse is caring for a client with a history of diverticulitis.

Correct Answer: A

Rationale: A low-fiber diet during acute diverticulitis episodes reduces bowel irritation. High-fiber is used for prevention, dairy is not restricted, and fluids are encouraged.

Question 4 of 5

The nurse is caring for a client with possible cervical cancer. What clinical data would the nurse most expect to find in the client's history?

Correct Answer: A

Rationale: Postcoital vaginal bleeding is a hallmark symptom of cervical cancer due to tumor involvement of the cervix. Nausea, vomiting, foul-smelling discharge, and hyperthermia may occur in advanced stages or infections but are less specific, so B, C, and D are incorrect.

Question 5 of 5

A 10-year-old child is admitted to the hospital with injuries. Which finding most suggests that additional assessment for child abuse is indicated?

Correct Answer: D

Rationale: Constant parental presence may indicate control or fear of the child disclosing abuse, warranting further abuse assessment.

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