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Questions 158

NCLEX-RN

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Extract:


Question 1 of 5

A client is having a pneumonectomy done today, and the nurse is planning her postoperative care. Nursing interventions for a postoperative left pneumonectomy would include:

Correct Answer: D

Rationale: Monitoring the right lung for an increase in rales is essential to detect early signs of fluid accumulation or infection in the remaining lung.

Question 2 of 5

A client reports to the nurse that the voices are practically nonstop and that he needs to leave the hospital immediately to find his girlfriend and kill her. The best verbal response to the client by the nurse at this time is:

Correct Answer: A

Rationale: This response validates the client's experience and presents reality to him. This nontherapeutic response minimizes and dismisses the client's verbalized experience. This response can be interpreted by a paranoid client as a threat, thereby increasing the client's potential for violence and loss of control. This response is also threatening. The client's behavior does not call for restraints because he has not lost control or hurt anyone. If seclusion or restraints were indicated, the nurse should never confront the client alone.

Question 3 of 5

What specific hormone must be present in serum or urine laboratory tests used to diagnose pregnancy?

Correct Answer: A

Rationale: Human chorionic gonadotropin is the biochemical basis for pregnancy tests, produced by the placenta to maintain the corpus luteum.

Question 4 of 5

Which of the following would the nurse expect to find following respiratory assessment of a client with advanced emphysema?

Correct Answer: A

Rationale: Distant breath sounds are characteristic of emphysema due to increased anteroposterior chest diameter, overdistention, and air trapping.

Question 5 of 5

The nurse is caring for a client after a burn. Which assessment finding best indicates that the client's respiratory efforts are currently adequate?

Correct Answer: C

Rationale: An O2 saturation of 97% directly indicates adequate oxygenation from respiratory efforts. Talking (
A), alertness (
B), and chest movement (
D) are indirect and less specific.

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