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

Questions 158

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Extract:


Question 1 of 5

A female client is seeking counseling for personal problems. She admits to being very unhappy lately at both home and work. During the nursing assessment, she uses many defense mechanisms. Which statement or action made by the client is an example of adaptive suppression?

Correct Answer: D

Rationale: This statement is an example of adaptive rationalization. She is coping with her disappointment by rationalizing. This is adaptive because no harm is done to self or others. It is used to protect her ego. This is an example of maladaptive suppression. She is suppressing the seriousness of the lump. It is maladaptive because delaying treatment will cause harm to her. The client's actions are an example of maladaptive denial. She is denying her son's death by not facing his possessions. Until she faces his death, she cannot face reality. This is an example of adaptive suppression. She realizes the impact of her husband's statement but delays discussion until she can devote her full attention to the matter.

Question 2 of 5

A client with gallstones and obstructive jaundice is experiencing severe itching. The physician has prescribed cholestyramine (Questran). The client asks, “How does this drug work?” What is the nurse’s best response?

Correct Answer: D

Rationale: Cholestyramine binds bile acids in the intestine, forming complexes excreted in stool, reducing circulating bile acids that cause itching. It doesn’t block histamine (
A), inhibit enzymes (
B), or reduce gallbladder bile (
C).

Question 3 of 5

Place in correct sequence the steps from 1-7 used when performing tracheostomy suctioning.

Order the Items

Source Container

Suction the oral cavity.
Auscultate breath sounds for effectiveness.
Set suction control at 80-120 mm Hg.
Ambu or oxygenate at 100% O2
Apply suction while withdrawing the suction catheter.
Turn the head toward the side to be suctioned.
Auscultate breath sounds prior to suctioning.

Correct Answer: G, C, D, F, E, B, A

Rationale: Sequence: Auscultate breath sounds (G), set suction pressure (
C), oxygenate (
D), turn head (F), apply suction (E), auscultate post-suction (
B), suction oral cavity (
A) to clean.

Question 4 of 5

A client with a history of a hiatal hernia is being taught about dietary management. The nurse should encourage the client to:

Correct Answer: B

Rationale: Caffeine relaxes the lower esophageal sphincter, worsening hiatal hernia symptoms. Small meals, avoiding lying down post-meals, and low-fat foods are recommended.

Question 5 of 5

The nurse is assessing breath sounds in a bronchovesicular client. She should expect that:

Correct Answer: D

Rationale: Inspiration is normally longer in vesicular areas. High-pitched sounds are normal in bronchial area. Muffled sounds are considered abnormal. Inspiration and expiration are equal normally in this area, and sounds are medium pitched.

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