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Questions 158

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NCLEX-RN Test Bank

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Extract:


Question 1 of 5

A client with a history of breast cancer is admitted with complaints of lymphedema. The nurse should give priority to:

Correct Answer: A

Rationale: Compression therapy reduces swelling in lymphedema post-breast cancer, improving comfort and function.

Question 2 of 5

The client is admitted with a diagnosis of abruptio placenta. Which vital sign change is most likely to be observed?

Correct Answer: D

Rationale: Abruptio placenta causes maternal tachycardia and hypotension (from bleeding) and fetal bradycardia (from hypoxia). All vital sign changes are likely in this condition.

Question 3 of 5

Hematotympanum and otorrhea are associated with which of the following head injuries?

Correct Answer: A

Rationale: Basilar skull fractures are fractures of the base of the skull. Blood behind the eardrum or blood or cerebrospinal fluid (CSF) leaking from the ear are indicative of a dural laceration. Basilar skull fractures are the only type with these symptoms.

Question 4 of 5

A client with vaginal cancer is being treated with a radioactive vaginal implant. The client's husband asks the nurse if he can spend the night with his wife. The nurse should explain that:

Correct Answer: D

Rationale: Radioactive implants emit radiation posing a risk to others. Visitation is limited to short periods (e.g. 30 minutes) to minimize radiation exposure. The other options do not address the safety concern related to radiation.

Question 5 of 5

Which guidelines would hamper staff learning and compliance?

Question Image

Correct Answer: E, F, G

Rationale: Providing all information in one session (E) can overwhelm staff, reducing retention. Stating changes are mandated (F) may foster resentment, decreasing compliance. Sending a memo about errors (G) may seem punitive, discouraging engagement. In contrast, scientific information (
A), clarification (
B), acknowledging resistance (
C), and diagrams (
D) promote understanding and acceptance.

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