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

Questions 148

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Extract:


Question 1 of 5

A client is admitted with acute adrenal crisis. During the intake assessment, the nurse can expect to find that the client has:

Correct Answer: A

Rationale: Acute adrenal crisis causes low blood pressure due to insufficient cortisol and aldosterone, leading to hypovolemia and shock.

Question 2 of 5

The nurse is caring for a client who has just been diagnosed with ovarian cancer. The nurse is using silence as an effective therapeutic response. How is silence an effective therapeutic response?

Correct Answer: C

Rationale: Silence gives the client space to process emotions and guide the conversation, enhancing therapeutic communication.

Question 3 of 5

The client with an abdominal aortic aneurysm is admitted in preparation for surgery. Which of the following should be reported to the doctor?

Correct Answer: A

Rationale: An elevated white blood cell count may indicate infection or inflammation, which requires prompt reporting before surgery.

Question 4 of 5

Place the steps for an abdominal assessment in the correct order.

Order the Items

Source Container

auscultation
palpation
inspection
percussion

Correct Answer: C,A,D,B

Rationale: Abdominal assessment order: inspection (visual assessment), auscultation (bowel sounds before manipulation), percussion (assess density), palpation (last to avoid altering bowel sounds).

Question 5 of 5

The client admitted 2 days earlier with a lung resection accidentally pulls out the chest tube. Which action by the nurse indicates understanding of the management of chest tubes?

Correct Answer: C

Rationale: Covering the insertion site with Vaseline gauze prevents air from entering the pleural space, which is the priority action for a dislodged chest tube.

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