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

Questions 158

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Question 1 of 5

A client's transfusion of packed red blood cells has been infusing for 2 hours. She is complaining of a raised, itchy rash and shortness of breath. She is wheezing, anxious, and very restless. The nurse knows these assessment findings are congruent with:

Correct Answer: D

Rationale: A hemolytic transfusion reaction would be characterized by fever, chills, chest pain, hypotension, and tachypnea. Fever, chills, and headaches are indicative of a febrile transfusion reaction. Circulatory overload is manifest by dyspnea, cough, and pulmonary crackles. Urticaria, pruritus, wheezing, and anxiety are indicative of an allergic transfusion reaction.

Question 2 of 5

A client with a history of a hiatal hernia is being taught about dietary management. The nurse should encourage the client to:

Correct Answer: B

Rationale: Caffeine relaxes the lower esophageal sphincter, worsening hiatal hernia symptoms. Small meals, avoiding lying down post-meals, and low-fat foods are recommended.

Question 3 of 5

A male client is scheduled to have angiography of his left leg. The nurse needs to include which of the following when preparing the client for this procedure?

Correct Answer: A

Rationale: Angiography, an invasive radiographic examination, involves the injection of a contrast solution (iodine) through a catheter that has been inserted into an artery. The client is kept on complete bed rest for 6-12 hours after the procedure. The extremity in which the catheter was inserted must be immobilized and kept straight during this time. The contrast dye, iodine, is nephrotoxic. The client must be instructed to drink a large quantity of fluids to assist the kidneys in excreting this contrast media. The major complication of this procedure is hemorrhage. Vital signs are assessed every 15 minutes initially for signs of bleeding.

Question 4 of 5

A client with an inguinal hernia asks the nurse why he should have surgery when he has had a hernia for years. The nurse understands that surgery is recommended to:

Correct Answer: A

Rationale: Surgery for an inguinal hernia is recommended to prevent strangulation, where the herniated bowel becomes trapped, leading to ischemia. The other options are not primary concerns.

Question 5 of 5

A 30-year-old client in the third trimester of her pregnancy asks the nurse for advice about upper respiratory discomforts. She complains of nasal stuffiness and epistaxis, most noticeable on the left side. Which reply by the nurse is correct?

Correct Answer: C

Rationale: Decongestants may exaggerate the nasal stuffiness associated with pregnancy. Judicious use of decongestants and nasal sprays is advocated during pregnancy. Cool air vaporizers and saline drops may help to relieve the nasal stuffiness. Positioning on either lateral side does not decrease nasal stuffiness or prevent epistaxis. Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation, which contributes to epistaxis. The nurse may recommend cool air vaporizers and saline drops to help with the nasal stuffiness. Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation discomforts associated with pregnancy.

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