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Questions 149

NCLEX-RN

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Question 1 of 5

A client in ICU has a chest tube, and the nurse is assessing the chest tube drainage system. The nurse notices intermittent bubbling in the water seal chamber. What action should the nurse take?

Correct Answer: B

Rationale: Intermittent bubbling in the water seal chamber is normal during inspiration/expiration or coughing, indicating a patent system. It should be documented as a normal finding.

Question 2 of 5

A client taking the drug disulfiram (Antabuse) is admitted to the ER. Which clinical manifestations are most indicative of recent alcohol ingestion?

Correct Answer: A

Rationale: Disulfiram causes a severe reaction with alcohol, including vomiting, tachycardia (HR 120), and chest pain due to acetaldehyde accumulation, making these symptoms most indicative.

Question 3 of 5

The nurse is caring for a client with pneumonia who is allergic to penicillin. Which antibiotic is safest to administer to this client?

Correct Answer: C

Rationale: Erythromycin is a macrolide, safe for penicillin-allergic clients, unlike cefazolin, amoxicillin, or ceftriaxone, which are beta-lactams with cross-reactivity risks.

Question 4 of 5

While reviewing the chart of a client with a history of hepatitis B, the nurse finds a serologic marker of HBsAg. The nurse recognizes that the client:

Correct Answer: A

Rationale: Presence of HBsAg indicates active hepatitis B infection, either acute or chronic, and potential infectivity.

Question 5 of 5

An elderly adult has been admitted with a diagnosis of hypertension with a history of dementia. Which of the following nursing diagnoses has the highest priority for this client?

Correct Answer: D

Rationale: Dementia increases fall and injury risk due to impaired judgment and memory, making 'risk for injury' the priority.

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