Questions 151

NCLEX-RN

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Extract:


Question 1 of 5

A client with a new colostomy asks the nurse how to prevent skin irritation around the stoma. What is the best response by the nurse?

Correct Answer: C

Rationale: A snug-fitting skin barrier and cleaning with mild soap prevent skin irritation by protecting the peristomal skin and maintaining hygiene without causing trauma.

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

The nurse is teaching a client with gout about dietary management. Which of the following foods should the client avoid?

Correct Answer: C

Rationale: Organ meats are high in purines, which increase uric acid levels and should be avoided in gout.

Question 4 of 5

The nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions is the highest priority to prevent ventilator-associated pneumonia?

Correct Answer: B

Rationale: Elevating the head of the bed to 30-45 degrees reduces the risk of aspiration, a key factor in preventing ventilator-associated pneumonia.

Question 5 of 5

The nurse is caring for a client with a history of burns. Which of the following complications should the nurse monitor for in the acute phase?

Correct Answer: A

Rationale: Hypovolemia is a major complication in the acute phase of burns due to fluid loss.

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