NCLEX Questions, NCLEX-RN Exam Questions, NCLEX-RN Questions, Nurselytic

Questions 158

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Question 1 of 5

A client with a gastrointestinal bleed has an NG tube to low continuous wall suction. Which technique is the correct procedure for the nurse to utilize when assessing bowel sounds?

Correct Answer: B

Rationale: Clamping the NG tube prevents suction noise, allowing accurate auscultation of bowel sounds. pH testing (
A) assesses gastric contents, irrigation (
C) is for patency, and high suction (
D) interferes with auscultation.

Question 2 of 5

A client scheduled for disc surgery tells the nurse that she frequently uses the herbal supplement kava-kava (piper methysticum). The nurse should notify the doctor because kava-kava:

Correct Answer: A

Rationale: Kava-kava can potentiate the effects of anesthesia and analgesics, increasing the risk of excessive sedation or respiratory depression, necessitating physician awareness.

Question 3 of 5

When assessing the client with acute arterial occlusion, the nurse would expect to find:

Correct Answer: B

Rationale: Acute arterial occlusion causes ischemia, leading to tissue necrosis, which may present as minute blackened areas on the toes, indicating severe ischemia.

Question 4 of 5

The nurse is caring for a client with a history of a pulmonary embolism. The client is receiving Heparin. The nurse should monitor the client for:

Correct Answer: A

Rationale: Heparin, an anticoagulant, increases bleeding risk, including bleeding gums. Hypertension, tachypnea, and fever are not directly related to heparin therapy.

Question 5 of 5

A client with a history of a brain tumor is scheduled for a craniotomy. The nurse should:

Correct Answer: B

Rationale: Antibiotics are often given preoperatively for a craniotomy to prevent infection. Shaving is per protocol, flat positioning may increase ICP, and exercises are taught post-op.

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