NCLEX Questions, NCLEX RN Practice Tests Questions, NCLEX-RN Questions, Nurselytic

Questions 149

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Question 1 of 5

A client has been on prolonged bedrest following surgery. The nurse notes that the patient has pain in the right calf on palpation with dorsiflexion of the ankle. Which of the following causes does the nurse suspect?

Correct Answer: D

Rationale: Calf pain with dorsiflexion (Homan's sign) suggests deep vein thrombosis (
D), common after prolonged bedrest. Arthritis (
A), muscle strain (
B), and compartment syndrome (
C) present differently.

Question 2 of 5

A burn client is in the acute phase of burn care. The nurse assesses jugular vein distention, edema, urine output of 20 cc in 2 hours, and crackles on auscultation. Which order would the nurse anticipate from the physician?

Correct Answer: A

Rationale: Signs of fluid overload (JVD, edema, low urine output, crackles) suggest the need for furosemide (Lasix) to reduce excess fluid and prevent pulmonary edema.

Question 3 of 5

A client has been instructed in the application and use of anti-embolic compression stockings. Which of the following statements by the client indicates a need for more teaching? Select all that apply.

Correct Answer: A,B,D

Rationale: Rolling the top down (
A) can impede circulation, removing stockings every 1-2 days (
B) is too infrequent (should be every 8 hours), and baby powder (
D) can cause skin irritation. Turning the stocking inside out (
C) and preventing clots (E) are correct.

Question 4 of 5

The physician has ordered 50 mEq of potassium chloride for a client with a potassium level of 2.5 mEq. The nurse should administer the medication:

Correct Answer: C

Rationale: Potassium chloride should be administered slowly (e.g., over 5 hours for 50 mEq) to prevent cardiac complications, as rapid infusion can cause hyperkalemia.

Question 5 of 5

The nurse is precepting a student nurse on an orthopedic floor. The student nurse needs to insert an indwelling catheter into a male client. Which of the following statements by the student nurse are correct regarding insertion of the catheter? Select all that apply.

Correct Answer: A,B,C

Rationale: Aseptic technique, supine positioning, and sterile lubrication are correct for catheter insertion. Inflating the balloon with 5 cc is incorrect, as most catheters require 10 cc of sterile water for balloon inflation.

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