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

Questions 149

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Question 1 of 5

A client has accidentally splashed a toxic (although not caustic) substance in his right eye and the nurse must flush the eye. Which of the following steps are correct? Select all that apply.

Correct Answer: B,C,D,E

Rationale: Correct eye irrigation includes syringe 0.5 inch above eye (
B), flushing 5 minutes (
C), holding eyelid open (
D), and using a basin (E). Head down (
A) is incorrect; tilt toward affected side.

Question 2 of 5

The nurse is caring for a client after a laryngectomy. The client is anxious, with a respiratory rate of 32 and an oxygen saturation of 88. The nurse's first action should be to:

Correct Answer: B

Rationale: Low oxygen saturation (88%) and high respiratory rate indicate hypoxemia. Increasing oxygen flow rate is the fastest way to improve oxygenation. Suctioning may be needed later, but oxygen is the priority.

Question 3 of 5

The nurse is caring for a client with amyotrophic lateral sclerosis (ALS, Lou Gehrig's disease). The nurse should give priority to:

Correct Answer: A

Rationale: Respiratory muscle weakness in ALS can lead to respiratory failure, making respiratory status assessment the priority.

Question 4 of 5

An important intervention in monitoring the dietary compliance of a client with bulimia is:

Correct Answer: C

Rationale: Observing the client after meals prevents purging, a common behavior in bulimia, ensuring dietary compliance and safety.

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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