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

Questions 149

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Extract:


Question 1 of 5

A client is admitted to an inpatient psychiatric unit after being found unresponsive as a result of prescribed opioid drugs. Upon awakening she attempts to get out of bed and is unsteady. The nurse is concerned that the client will fall. The doctor ordered a vest restraint to be applied as necessary to maintain client safety. The client refuses the restraints. The nurse should take which of the following actions?

Correct Answer: A

Rationale: Moving the client closer to the nursing station allows close monitoring without violating the client’s refusal of restraints, prioritizing safety and autonomy.

Question 2 of 5

Which of the following findings would be expected in the infant with biliary atresia?

Correct Answer: C

Rationale: Biliary atresia causes abdominal distention due to bile accumulation and poor weight gain due to malabsorption.

Question 3 of 5

A client with end-stage renal failure receives hemodialysis via an arteriovenous fistula (AV) placed in the right arm. When caring for the client, the nurse should:

Correct Answer: C

Rationale: Auscultating for a bruit confirms AV fistula patency, which is critical for hemodialysis.

Question 4 of 5

The nurse is preparing a 73-year-old client for cataract surgery on the left eye. Which statement by the client indicates a need for further teaching?

Correct Answer: C

Rationale: Stopping Coumadin without medical guidance is unsafe, as it may increase clotting risk, indicating a need for further teaching.

Question 5 of 5

A client is being assessed for neutropenia. The client's total white blood cell count is 5200 with 45% neutrophils and 5% bands. What is the absolute neutrophil count (ANC)? Record your answer using a whole number.

Correct Answer: 2600

Rationale: ANC = WBC X (Neutrophils% + Bands%) = 5200 X (0.45 + 0.05) = 5200 X 0.5 = 2600.

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