Questions 151

NCLEX-RN

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Extract:


Question 1 of 5

A client with a spinal cord injury is at risk for autonomic dysreflexia. Which symptom should the nurse monitor for?

Correct Answer: C

Rationale: Severe headache is a key sign of autonomic dysreflexia, often triggered by bladder or bowel issues.

Question 2 of 5

A comprehensive health assessment includes:

Correct Answer: A

Rationale: A comprehensive health assessment includes a complete medical history, a general survey (vital signs, appearance), and a complete physical assessment covering all body systems.

Question 3 of 5

A client is taking 600 mg of valproic acid (Depakene) twice daily. The nurse should assess the client for which of the following? Select all that apply.

Correct Answer: A,C,E

Rationale: Valproic acid commonly causes tremors, gastrointestinal upset (e.g., nausea), and weight gain. Hair loss and anorexia are less common side effects.

Question 4 of 5

A client with a history of type 2 diabetes is prescribed glipizide (Glucotrol). The nurse should instruct the client to:

Correct Answer: A, B

Rationale: Glipizide should be taken 30 minutes before meals to optimize glucose control, and alcohol should be avoided to prevent hypoglycemia.

Question 5 of 5

Select the basic sterile asepsis procedures that are accurate. Select all that apply:

Correct Answer: A,C,E

Rationale: Sterile items only on the sterile field , coughing/sneezing contaminating the field , and moisture contaminating the field are accurate sterile asepsis principles. The sterile field must be above waist level (B is incorrect), a 1-inch border is standard (D is incorrect), and masks are not required for clients (F is incorrect).

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