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

Questions 158

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Question 1 of 5

A client with sickle cell disease is admitted in active labor. Which nursing intervention would be most helpful in preventing a sickling crisis?

Correct Answer: D

Rationale: IV fluids at 200 mL/hr prevent dehydration, a trigger for sickling crises, by maintaining hydration and blood flow. BP monitoring (
A), pain medication (
B), and ABGs (
C) are supportive but less directly preventive.

Question 2 of 5

A client is admitted with sickle cell crises and sequestration. Upon assessing the client, the nurse would expect to find:

Correct Answer: A

Rationale: Sickle cell crisis with sequestration can lead to hypovolemia due to blood pooling in organs, resulting in decreased blood pressure.

Question 3 of 5

The nurse is teaching a 10-year-old insulin-dependent diabetic how to administer insulin. Which one of the following steps must be taught for insulin administration?

Correct Answer: B

Rationale: Sites for injection need to be rotated, including abdominal sites, to enhance insulin absorption. The pinch technique is the most effective method for obtaining skin tightness to allow easy entrance of the needle to subcutaneous tissues. Massaging the site of injection facilitates absorption of the insulin. Changing the needle will break the sterility of the system. It has become acceptable practice to reuse disposable needles and syringes for 3-7 days.

Question 4 of 5

A client is hyperactive and not sleeping. She will not remain at the table during mealtime. She is getting very limited calories and is using a lot of energy in her hyperactive state. The most therapeutic nursing action is to:

Correct Answer: C

Rationale: Providing finger foods increases the likelihood of eating for hyperactive persons. They may be eating 'on the run,' accommodating their high energy state.

Question 5 of 5

A client is admitted to the emergency room with a gunshot wound to the right arm. After dressing the wound and administering the prescribed antibiotic, the nurse should:

Correct Answer: C

Rationale: Immobilizing the arm with a splint is critical to prevent further damage to the injured area, reduce pain, and promote healing. Asking about allergies should have been done prior to administering antibiotics, checking immunization records is not a priority in this acute situation, and pain medication, while important, is secondary to stabilizing the injury.

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