NCLEX Questions, NCLEX RN Practice Test Questions, NCLEX-RN Questions, Nurselytic

Questions 149

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Question 1 of 5

A client arrives from surgery following an abdominal perineal resection with a permanent ileostomy. What should be the priority nursing care during the post-op period?

Correct Answer: D

Rationale: Facilitating perineal wound drainage is the priority to prevent infection and promote healing in the immediate postoperative period, as the perineal wound is at high risk for complications.

Question 2 of 5

The nurse is suspected of charting medication administration that he did not give. After talking to the nurse, the charge nurse should:

Correct Answer: B

Rationale: Suspected falsification of records warrants a formal reprimand and investigation, but immediate termination or legal action requires further evidence.

Question 3 of 5

A client with a total knee replacement has a CPM (continuous passive motion device) applied during the post-operative period. Which statement made by the nurse indicates understanding of the CPM machine?

Correct Answer: C

Rationale: Pain during CPM use may indicate improper settings or complications, requiring physician notification.

Question 4 of 5

A 2-year-old is admitted for repair of a fractured femur and is placed in Bryant's traction. Which finding by the nurse indicates that the traction is working properly?

Correct Answer: B

Rationale: In Bryant's traction, the buttocks should be slightly elevated (15° off the bed) to ensure proper alignment.

Question 5 of 5

The nurse is caring for a manic client in the seclusion room, and it is time for lunch. It is MOST appropriate for the nurse to take which of the following actions?

Correct Answer: D

Rationale: should eat at regular time; remain in the seclusion room for client’s safety

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