Questions 150

NCLEX-RN

NCLEX-RN Test Bank

RN NCLEX Next Gen Questions Questions

Extract:


Question 1 of 5

A 4-year-old child who has been ill for 4 hours is admitted to the hospital with difficulty swallowing, a sore throat, and severe substernal retractions. The child's temperature is 104°F (40°C), and the apical pulse is 140 bpm.The white blood cell count is 16,000/mm³. Which of the following should the nurse identify as the immediate priority nursing diagnosis?

Correct Answer: B

Rationale: The symptoms indicate epiglottitis, with a high risk of airway obstruction due to epiglottal edema, making this the priority diagnosis.

Question 2 of 5

Which of the following is an adverse effect to therapeutic radiation therapy?

Correct Answer: D

Rationale: Xerostomia (dry mouth) is a common adverse effect of radiation therapy, particularly when the head or neck is irradiated, due to damage to salivary glands.

Question 3 of 5

Which of the following statements best explains why the nurse should evaluate gastric residual in administering the client's next enteral feeding?

Correct Answer: C

Rationale: Evaluating gastric residual prevents overdistention of the stomach, which can lead to aspiration or discomfort. It does not directly assess nutrient absorption or feeding adequacy.

Question 4 of 5

The nurse is caring for a client who has just undergone a colectomy. Which of the following interventions is most important in the immediate postoperative period?

Correct Answer: B

Rationale: Encouraging early ambulation post-colectomy prevents complications like ileus and deep vein thrombosis.

Question 5 of 5

Which type of legal consent is indirectly given by the client by the very nature of their voluntary acute care hospitalization?

Correct Answer: B

Rationale: Implicit consent is given by the client's voluntary admission to an acute care facility, implying agreement to routine treatments and procedures necessary for their care, unless explicitly refused.

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