NCLEX-RN
NCLEX RN High-Yield Questions Questions
Extract:
Question 1 of 5
A client's chest tube is connected to a drainage system with a water seal. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. The fluctuation means that:
Correct Answer: C
Rationale: Fluctuation in the water-seal column with breathing indicates the chest tube is patent and functioning correctly, reflecting intrathoracic pressure changes.
Question 2 of 5
Intravenous 5% albumin is prescribed for a client with burns of the anterior chest and both legs. The nurse contacts the primary health care provider before administering the human albumin if which are noted in the client's record? Select all that apply.
Correct Answer: A,D
Rationale: Five percent albumin is classified as a blood derivative and is contraindicated in severe anemia, cardiac failure, history of allergic reaction, renal insufficiency, and when no albumin deficiency is present. It is used with caution in clients with low cardiac reserve, pulmonary disease, or hepatic or renal failure.
Question 3 of 5
When planning the care for a client diagnosed with hepatitis A, which of the following nursing interventions should the nurse expect to include? Select all that apply.
Correct Answer: B,D,E
Rationale: Hepatitis A care includes relieving nausea and vomiting, encouraging small meals to improve nutrition, and planning rest periods due to fatigue. Exercise and pain medication are not typically needed.
Question 4 of 5
The nurse is making rounds and observes a client who is unconscious (see fi gure). The nursing assistant has just turned the client from lying on her back. Before raising the side rail, the nurse should:
Correct Answer: C
Rationale: The client is positioned correctly in the side-lying position. The pillows support the client’s joints and do not cause unnecessary pressure on the joints or skin. It is not necessary to add another pillow under the arm or to elevate the head of the bed. The nurse should assess the client’s skin for signs of breakdown, particularly at the elbows, back, hips, and heels where there were pressure points from the position in which the client was previously lying.
Question 5 of 5
The nurse teaches the client with cirrhosis that he is achieving the expected effect of lactulose (Cephulac) when he has:
Correct Answer: B
Rationale: Lactulose is used in cirrhosis to reduce ammonia levels by promoting 2–3 soft stools per day. Fewer or more frequent stools may indicate under- or overdosing.