NCLEX Questions, NCLEX Practice Test RN Questions, NCLEX-RN Questions, Nurselytic

Questions 158

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Question 1 of 5

A client with an abdominal aortic aneurysm is admitted in preparation for surgery. Which finding should be reported to the doctor?

Correct Answer: A

Rationale: A WBC of 14,000 cu.mm indicates possible infection or inflammation, which is concerning pre-surgery and should be reported. Abdominal bruit and lower back pain are expected with an abdominal aortic aneurysm, and a platelet count of 175,000 is normal.

Question 2 of 5

An appropriate nursing intervention for the client with borderline personality disorder is:

Correct Answer: A

Rationale: Clients with borderline personality disorder often experience mood instability and are at risk for self-harm or suicide. Observing for signs of depression or suicidal thinking is a priority nursing intervention to ensure safety. Allowing the client to lead group sessions or select a caregiver may reinforce manipulative behaviors, and restricting activity to the unit is not typically therapeutic unless specified for safety.

Question 3 of 5

A client with a history of breast cancer is receiving tamoxifen (Nolvadex). Which adverse effect should the nurse monitor for?

Correct Answer: B

Rationale: Tamoxifen increases the risk of endometrial hyperplasia, a serious adverse effect due to its estrogenic effects on the uterus. Weight loss (
A), hypotension (
C), and hair loss (
D) are not typical.

Question 4 of 5

The school nurse is assessing an elementary student with hemophilia who fell during recess. Which symptoms indicate hemarthrosis?

Correct Answer: D

Rationale: Hemarthrosis in hemophilia involves bleeding into joints, causing stiffness, aching, and decreased movement due to joint swelling and pain.

Question 5 of 5

The nurse is caring for an obstetrical client in early labor. After the rupture of membranes, the nurse should give priority to:

Correct Answer: B

Rationale: After rupture of membranes, assessing fetal heart tones is critical to detect distress, such as cord prolapse. Monitoring, anesthesia, and catheterization are secondary priorities.

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