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 liver cirrhosis is admitted with complaints of ascites. The nurse should give priority to:

Correct Answer: A

Rationale: Ascites increases infection risk (e.g., spontaneous bacterial peritonitis) in cirrhosis, so monitoring for infection is the priority.

Question 2 of 5

The client with cancer refuses to care for herself. Which action by the nurse would be best?

Correct Answer: C

Rationale: Exploring the reason for the client’s refusal to self-care (e.g., depression, pain, or fear) is the best approach, as it addresses the underlying cause and guides interventions. Alternating nurses avoids the issue, explaining self-care may not address motivation, and consulting the physician is secondary.

Question 3 of 5

A client is diagnosed with diabetic ketoacidosis. The nurse should be prepared to administer which of the following IV solutions?

Correct Answer: C

Rationale: A concentration of 0.9 NS is used to correct extracellular fluid depletion.

Question 4 of 5

The nurse would need to monitor the serum glucose levels of a client receiving which of the following medications, owing to its effects on glycogenolysis and insulin release?

Correct Answer: D

Rationale: Norepinephrine's side effects are primarily related to safe, effective care environment and include decreased peripheral perfusion and bradycardia. Dobutamine's side effects include increased heart rate and blood pressure, ventricular ectopy, nausea, and headache. Propranolol's side effects include elevated blood urea nitrogen, serum transaminase, alkaline phosphatase, and lactic dehydrogenase. Epinephrine increases serum glucose levels by increasing glycogenolysis and inhibiting insulin release. Prolonged use can elevate serum lactate levels, leading to metabolic acidosis, increased urinary catecholamines, false elevation of blood urea nitrogen, and decreased coagulation time.

Question 5 of 5

Joint Commission has established protocols for preventing surgical errors. Which steps are parts of that protocol?

Order the Items

Source Container

Circle the surgical site with a marker.
Verify patient information with a designated patient representative.
Designate operative site with a facility designated mark.
Include a copy of the Advanced Directives on the chart before surgery.
Verify patient information three times.
Observe pre-op time out before proceeding with surgery.

Correct Answer: C, E, F

Rationale: Joint Commission protocols include marking the site with a facility-designated mark (
C), verifying patient information multiple times (E), and performing a pre-op time-out (F). Circling the site (
A) is not standard. Patient representative verification (
B) and advance directives (
D) are not part of site verification.

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