NCLEX Questions, NCLEX RN Predictor Exam Questions, NCLEX-RN Questions, Nurselytic

Questions 158

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Question 1 of 5

A client is 2 hours post ventriculoperitoneal shunt placement. How should the nurse position the client?

Correct Answer: D

Rationale: Flat position on nonoperative side in the immediate postoperative period prevents pressure on shunt valve and rapid reduction in cerebrospinal fluid.

Question 2 of 5

A client's record from the ED indicates that she overdosed on phenelzine sulfate (Nardil), a monoamine oxidase (MAO) inhibitor. Which diet would be the most appropriate at this time?

Correct Answer: D

Rationale: Tyramine is an amino acid activated by MAO in the liver and intestinal wall. It is released as proteins are hydrolyzed through aging, pickling, smoking, or spoilage of foods. When MAO is inhibited, tyramine levels rise, stimulating the adrenergic system to release large amounts of norepinephrine, which can produce a hypertensive crisis.

Question 3 of 5

The nurse is caring for a client with a diagnosis of ectopic pregnancy. Which intervention is most appropriate?

Correct Answer: A

Rationale: Ectopic pregnancy requires surgical intervention (e.g. salpingectomy) or medical management (e.g. methotrexate) to remove the non-viable pregnancy.
Tocolytics fetal monitoring and antibiotics are not appropriate.

Question 4 of 5

The nurse notes multiple bruises on the arms and legs of a newly admitted client with lupus. The client states, 'I get them whenever I bump into anything.' The nurse would expect to note a decrease in which of the following laboratory tests?

Correct Answer: A

Rationale: Thrombocytopenia, a decrease in platelets, occurs in lupus and causes a decrease in blood coagulation and thrombus formation. Clients with lupus will have a decrease in the WBC count decreasing their resistance to infection. Clients with lupus may have a decrease in the hemoglobin level causing anemia. Leukopenia, a decrease in white blood cells, is seen in lupus and decreases resistance to infection.

Question 5 of 5

Which statement is true regarding a patient with a Sengstaken-Blakemore tube?

Correct Answer: D

Rationale: A Sengstaken-Blakemore tube is used for esophageal variceal bleeding. Scissors must be kept at the bedside to cut the tube in case of airway obstruction from balloon migration. The gastric balloon (not esophageal) controls bleeding the tube has three lumens and esophageal balloon pressure is typically 20-25 mmHg.

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