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

Questions 158

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Extract:


Question 1 of 5

A healthcare worker is referred to the nursing office with a suspected latex allergy. The first symptom of latex allergy is usually:

Correct Answer: D

Rationale: Latex allergy often first presents as localized skin reactions, such as swelling and itching of the hands, due to direct contact with latex products.

Question 2 of 5

In assessing the nature of the stool of a client who has cystic fibrosis, what would the nurse expect to see?

Correct Answer: B

Rationale: Clay-colored stools indicate dysfunction of the liver or biliary tract. In the early stages of cystic fibrosis, fat absorption is primarily affected resulting in fat, foul, frothy, bulky stools. Dark brown stools indicate normal passage through the colon. Blood-tinged stools indicate dysfunction of the gastrointestinal (GI) tract.

Question 3 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, essential for ileostomy care. Stoma massage (
A) is unnecessary, high-fiber foods like nuts (
B) may cause blockages, and limiting fluids (
C) risks dehydration.

Question 4 of 5

A 48-year-old client is being seen in her physician's office for complaints of indigestion, heartburn, right upper quadrant pain, and nausea of 4 days' duration, especially after meals. The nurse realizes that these symptoms may be associated with cholecystitis and therefore would check for which specific sign during the abdominal assessment?

Correct Answer: C

Rationale: This sign is a faint blue discoloration around the umbilicus found in clients who have hemorrhagic pancreatitis. This sign indicates areas of inflammation within the peritoneum, such as with appendicitis. It is a deep palpation technique used on a nontender area of the abdomen, and when the palpating hand is removed suddenly, the client experiences a sharp, stabbing pain at an area of peritoneal inflammation. This sign is considered positive with acute cholecystitis when the client is unable to take a deep breath while the right upper quadrant is being deeply palpated. The client will elicit a sudden, sharp gasp, which means the gallbladder is acutely inflamed. This is a sign of acute hemorrhagic pancreatitis and manifests as a green or purple discoloration in the flanks.

Question 5 of 5

A gravida 2 para 1 client is hospitalized with severe preeclampsia. While she receives magnesium sulfate (MgSO4) therapy, the nurse knows it is safe to repeat the dosage if:

Correct Answer: D

Rationale: Respirations >16 breaths/min indicate that toxic magnesium levels have not been reached, making it safe to repeat the dose.

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