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

Questions 149

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Question 1 of 5

A client in restraints is assigned to a newly graduated nurse. The nurse understands that which of the following are true regarding restraints? Select all that apply.

Correct Answer: A, C, F

Rationale: Restraints include chemical, mechanical, or physical methods; bed rails are restraints if used to restrict movement; and non-restraint alternatives like active listening are preferred. Pediatric time limits and reassessment frequency vary by policy, and reapplication requires new orders.

Question 2 of 5

A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates understanding of phantom limb pain?

Correct Answer: B

Rationale: Phantom limb pain results from peripheral nervous system interruptions, and offering pain medication addresses the client's discomfort appropriately.

Question 3 of 5

The nurse is caring for a client with a history of breast cancer who is receiving tamoxifen (Nolvadex). The nurse should instruct the client to report which of the following side effects?

Correct Answer: C

Rationale: vaginal bleeding is a serious side effect of tamoxifen, as it may indicate endometrial cancer

Question 4 of 5

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. The nurse notes that the client has a respiratory rate of 28 breaths per minute, is using accessory muscles, and has oxygen saturation of 88% on 2 L/min of oxygen via nasal cannula. Which of the following actions should the nurse take FIRST?

Correct Answer: C

Rationale: positioning in high Fowler’s facilitates breathing and improves oxygenation immediately; other actions may follow based on further assessment

Question 5 of 5

Which play activity is best suited to the gross motor skills of the toddler?

Correct Answer: B

Rationale: Playing with a ball encourages gross motor skills like kicking and throwing, suitable for a toddler's developmental stage.

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