NCLEX Questions, NCLEX RN Practice Questions Quizlet Questions, NCLEX-RN Questions, Nurselytic

Questions 149

NCLEX-RN

NCLEX-RN Test Bank

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Question 1 of 5

A client with inflammatory bowel disease (IBD) requires an ileostomy. The nurse would instruct the client to do which of the following measures as an essential part of caring for the stoma?

Correct Answer: D

Rationale: Meticulous cleansing of the peristomal skin prevents irritation and infection, which is critical for ileostomy care.

Question 2 of 5

The client has an order for heparin to prevent post-surgical thrombi. Immediately following a heparin injection, the nurse should:

Correct Answer: D

Rationale: Checking the site for bleeding ensures early detection of hematoma or excessive bleeding post-heparin injection.

Question 3 of 5

The nurse is discussing meal planning with the mother of a 2-year-old. Which of the following statements, if made by the mother, would require a need for further instruction?

Correct Answer: C

Rationale: Hot dogs pose a choking hazard for a 2-year-old due to their size and texture, requiring further instruction.

Question 4 of 5

A client with burns is admitted and fluid resuscitation has begun. Central venous pressure (CVP) readings are ordered every 4 hours; the client's CVP reading is 14 cm/Hâ‚‚O. Which evaluation by the nurse would be most accurate?

Correct Answer: D

Rationale: A CVP of 14 cm/Hâ‚‚O (normal: 3-8 cm/Hâ‚‚O) indicates fluid volume excess, likely from aggressive resuscitation, requiring careful monitoring to prevent complications.

Question 5 of 5

The nurse is caring for a patient with suspected diverticulitis. The nurse would be most prudent in questioning which of the following diagnostic tests?

Correct Answer: B

Rationale: A barium enema is contraindicated in acute diverticulitis due to the risk of perforation and peritonitis.

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