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Questions 149

NCLEX-RN

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Question 1 of 5

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. The nurse notes that the client has a respiratory rate of 28 breaths per minute, is using accessory muscles, and has oxygen saturation of 88% on 2 L/min of oxygen via nasal cannula. Which of the following actions should the nurse take FIRST?

Correct Answer: C

Rationale: positioning in high Fowler’s facilitates breathing and improves oxygenation immediately; other actions may follow based on further assessment

Question 2 of 5

A client in restraints is assigned to a newly graduated nurse. The nurse understands that which of the following are true regarding restraints? Select all that apply.

Correct Answer: A, C, F

Rationale: Restraints include chemical, mechanical, or physical methods; bed rails are restraints if used to restrict movement; and non-restraint alternatives like active listening are preferred. Pediatric time limits and reassessment frequency vary by policy, and reapplication requires new orders.

Question 3 of 5

A client is being treated for irritable bowel syndrome (IBS). The nurse knows that the involvement of nursing, pharmacy, gastroenterology, and nutritional services is an example of which of the following approaches?

Correct Answer: B

Rationale: A multidisciplinary approach involves multiple specialties (nursing, pharmacy, gastroenterology, nutrition) collaborating to manage IBS.

Question 4 of 5

The nurse is caring for a client with bulimia nervosa. The nurse recognizes that the major difference in the client with anorexia nervosa and the client with bulimia nervosa is the client with bulimia:

Correct Answer: C

Rationale: Clients with bulimia often recognize their eating disorder, unlike those with anorexia, who may deny the problem due to distorted body image.

Question 5 of 5

A client diagnosed with hemophagocytic lymphohistiocytosis requires multiple blood transfusions. One of his family members wishes to donate blood. Which of the following conditions would DISQUALIFY someone from donating blood?

Correct Answer: C

Rationale: Current illness (e.g., cold) disqualifies blood donation due to infection risk. Hyperthyroidism, postpartum (after 6 months), and treated TB (if fully recovered) may not disqualify.

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