Questions 151

NCLEX-RN

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Question 1 of 5

A client with a history of cardiac problems is having severe chest pain. What should be nurse's first response?

Correct Answer: C

Rationale: Assessing the client's chest pain is the first step to determine its nature and severity, guiding further actions like notifying the physician or administering oxygen or analgesics.

Question 2 of 5

A client with a history of stroke is prescribed clopidogrel (Plavix). The nurse should monitor the client for which of the following adverse effects?

Correct Answer: A

Rationale: Clopidogrel, an antiplatelet, increases bleeding risk, requiring monitoring.

Question 3 of 5

When a rubella vaccine is administered to a client who delivered a healthy newborn 2 days ago, the nurse provides instructions to the client regarding the potential risks associated with this vaccination. Which statement by the client indicates an understanding of the medication?

Correct Answer: D

Rationale: Rubella vaccine is a live attenuated virus that evokes an antibody response and provides immunity for approximately 15 years. Because rubella is a live vaccine, it will act as the virus and is potentially teratogenic in the organogenesis phase of fetal development. The client needs to be informed about the potential effects this vaccine may have and the need to avoid becoming pregnant for a period of 2 to 3 months afterward. Sunlight has no effect on the person who is vaccinated. The vaccine may cause local or systemic reactions, but all are mild and short-lived. Abstinence from sexual intercourse is not necessary, unless another form of effective contraception is not being used.

Question 4 of 5

When developing the plan of care for a 12-year-old child who is to receive 48 hours of chemotherapy that is associated with nausea and vomiting, at which of the following times should the nurse anticipate administering an antiemetic?

Correct Answer: B

Rationale: Administering an antiemetic 30 minutes before chemotherapy and every 4-6 hours prophylactically minimizes nausea and vomiting.

Question 5 of 5

The nurse is involved in preoperative teaching with a client who will be undergoing a lung resection. The client is told that two chest tubes will be placed during surgery. The nurse explains that the purpose of the nurse is to:

Correct Answer: B, C

Rationale: Chest tubes are placed to remove air (pneumothorax) and fluid (hemothorax or pleural effusion) from the pleural space to restore negative pressure and lung expansion. Preventing clots or milking tubes is not their primary purpose.

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