Questions 150

NCLEX-RN

NCLEX-RN Test Bank

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Question 1 of 5

A client with type 1 diabetes mellitus is admitted with hyperglycemia. The nurse should assess the client for which of the following signs of diabetic ketoacidosis (DKA)? Select all that apply.

Correct Answer: A, B, D, E

Rationale: DKA presents with fruity breath (due to acetone), Kussmaul respirations (compensatory hyperventilation), polyuria (osmotic diuresis), and hypotension (dehydration). Bradycardia is not typical.

Question 2 of 5

The nurse notices drops of a liquid on the hallway floor of a health care facility. The nurse should do which of the following first?

Correct Answer: C

Rationale: Posting 'wet floor' signs first ensures immediate safety by alerting others to the hazard, preventing slips.
Then, the nurse can proceed with cleanup or notify appropriate personnel.

Question 3 of 5

The nurse is caring for a client with a chest tube. Which of the following findings requires immediate intervention?

Correct Answer: B

Rationale: Clamping the tubing near the insertion site can cause a tension pneumothorax, requiring immediate correction.

Question 4 of 5

A client with pneumonia is receiving oxygen at 2 L/min via nasal cannula. The nurse notes a respiratory rate of 30 breaths/min and oxygen saturation of 88%. What should the nurse do first?

Correct Answer: B

Rationale: An oxygen saturation of 88% and tachypnea indicate worsening hypoxia, requiring immediate physician notification for further orders. Increasing oxygen or repositioning may help but requires a prescription.

Question 5 of 5

The nurse is caring for a client with a fracture of a long bone. Which of the following assessments would be the earliest symptom of a fat embolism?

Correct Answer: A

Rationale: Respiratory distress is the earliest symptom of fat embolism syndrome, as emboli obstruct pulmonary circulation, leading to hypoxia.

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