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

Questions 158

NCLEX-RN

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Question 1 of 5

A client's physician has prescribed theophylline (Theo-Dur) to help control the bronchospasm associated with the client's COPD. Instructions that should be given to the client include:

Correct Answer: A

Rationale: Theophylline toxicity can manifest as palpitations, dizziness, or restlessness, requiring immediate medical attention.

Question 2 of 5

Which of the following foods,if selected by the mother of a child with celiac disease would indicate her understanding of the dietary instructions?

Question Image

Correct Answer: D

Rationale: Celiac disease requires a gluten-free diet. Rice cereal is gluten-free unlike whole-wheat toast pasta and rye bread which contain gluten and are contraindicated.

Question 3 of 5

A 40-year-old client has been admitted to the hospital with severe substernal chest pain radiating down his left arm. The nurse caring for the client establishes the following priority nursing diagnosis--Alteration in comfort, pain related to:

Correct Answer: A

Rationale: Anaerobic metabolism results because the decreased blood supply to the myocardium causes a release of lactic acid. Lactic acid is an irritant to the myocardial neural receptors, producing chest pain. Chest pain is caused by a decrease in the O2 supply to the myocardial cells. Treatment modalities for chest pain are aimed toward increasing the blood flow through coronary arteries. Chest pain causes an increase in the stimulation of the sympathetic nervous system. This stimulation increases the heart rate and blood pressure, causing an increase in myocardial workload aggravating the chest pain. Chest pain and anxiety cause increased secretion of catecholamines by stimulating the sympathetic nervous system. This stimulation increases chest pain by increasing the workload of the heart.

Question 4 of 5

On the third postpartum day, a client complains of extremely tender breasts. On palpation, the nurse notes a very firm, shiny appearance to the breasts and some milk leakage. She is bottle feeding. The nurse should initially recommend to her to:

Correct Answer: C

Rationale: Judicious use of analgesics is appropriate with breast engorgement; however, mechanical suppression would be the initial recommendation. Breast-feeding every 1½-3 hours will reduce and/or prevent breast engorgement. Breast-feeding will promote milk production, which will compound the distention and stasis of the venous circulation of engorgement in a bottle-feeding mother. Ice packs reduce milk flow while the snug, supportive bra provides mechanical suppression and decreases pulling on Cooper's ligament. In addition, breast binders or ace bandages may be used for some women. Warmth promotes milk production and may stimulate the let-down reflex. These measures would contribute to the venous congestion of engorgement.

Question 5 of 5

The nurse is caring for a client with a diagnosis of hepatitis who is experiencing pruritis. Which would be the most appropriate nursing intervention?

Correct Answer: B

Rationale: Adding baby oil to bath water moisturizes skin, relieving pruritus in hepatitis. Warm showers (
A) and hot rinses (
D) may worsen itching, and powder (
C) can dry skin further.

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