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

Questions 158

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Extract:


Question 1 of 5

A client with a history of atrial fibrillation is admitted with complaints of palpitations. The nurse should expect the client to have:

Correct Answer: A

Rationale: Atrial fibrillation causes an irregular pulse due to disorganized atrial contractions, a hallmark of the condition.

Question 2 of 5

During morning assessments, the nurse finds that a client's nephrostomy tube has been clamped. The nurse's first action should be to:

Correct Answer: C

Rationale: Unclamping the nephrostomy tube is the priority to restore urine flow and prevent complications like hydronephrosis or infection.

Question 3 of 5

Before completing a nursing diagnosis, the nurse must first:

Correct Answer: B

Rationale: Assessment is the first step of nursing process.

Question 4 of 5

The nurse is caring for a client with a history of a stroke who has hemiparesis. The nurse should:

Correct Answer: D

Rationale: A sling supports the affected arm in hemiparesis, preventing subluxation. Positioning varies, passive motion is secondary, and diet depends on needs.

Question 5 of 5

A 23-year-old male client is admitted to the chemical dependency unit with a medical diagnosis of alcoholism. He reports that the last time he drank was 3 days ago, and that now he is starting to 'feel kind of shaky.' Based on the information given above, nursing care goals for this client will initially focus on:

Correct Answer: D

Rationale: Self-concept and self-esteem problems may emerge during the client's treatment, but these are not immediate concerns. Interpersonal issues may become evident during the course of the client's treatment, but these are also not immediate areas of concern. Improving individual coping skills is generally a primary focus in the treatment and nursing care of persons with substance abuse problems. However, this is still not the immediate concern in this client situation. Correction of fluid and electrolyte status and vitamin deficiencies, as well as prevention of delirium, is the immediate concern in the care of this client.

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