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Questions 158

NCLEX-RN

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Extract:


Question 1 of 5

A client had abdominal surgery this morning. The nurse notices that there is a small amount of bloody drainage on his surgical dressing. The nurse would document this as what type of drainage?

Correct Answer: C

Rationale: Drainage from a surgical incision is initially sanguinous, proceeding to serosanguinous, and then to serous.

Question 2 of 5

A client with a history of hypothyroidism is admitted with complaints of fatigue. The nurse should expect the client to have:

Correct Answer: A

Rationale: Hypothyroidism slows metabolism, leading to weight gain, fatigue, and other symptoms like cold intolerance and constipation.

Question 3 of 5

Which of the following is not a step in primary assessment of a client presenting to the emergency department after being involved in a motor vehicle accident?

Correct Answer: B

Rationale: Primary assessment in trauma follows the ABCDE approach (Airway Breathing Circulation Disability Exposure). Obtaining vital signs is part of the secondary assessment not the primary survey which focuses on immediate life threats like airway bleeding and responsiveness.

Question 4 of 5

A physician tells the nurse that he wants to orally intubate a client with a No. 8 endotracheal tube. The finding of normal breath sounds on the right side of the chest and diminished, distant breath sounds on the left side of the chest of a newly intubated client is probably due to:

Correct Answer: C

Rationale: The right mainstem bronchus is most frequently intubated in error because the angle of the right mainstem bronchus is very small as compared with that of the left mainstem bronchus. Because ventilation is only occurring on the right side, the nurse would auscultate diminished and distant breath sounds on the left.

Question 5 of 5

The nurse is preparing to receive a client from admitting with tumor lysis syndrome (TLS). Which of the following would the nurse expect to find on the laboratory and patient history sections of the chart?

Correct Answer: A,C,D,E

Rationale: TLS causes hyperkalemia (
C), hyperuricemia (
D), and mental changes (E) due to electrolyte imbalances and low blood pressure (
A) from fluid shifts. Hyperactivity (
B) is not typical.

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