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Questions 149

NCLEX-RN

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Extract:


Question 1 of 5

A patient refuses to take his dose of oral medication. The nurse tells the patient that if he does not take the medication that she will administer it by injection. The nurse's comments can result in a charge of:

Correct Answer: B

Rationale: Threatening to administer medication by injection against the patient's will constitutes assault, as it involves a threat of unwanted contact.

Question 2 of 5

The nurse is caring for a Muslim client who is recovering from an automobile accident and is unable to cleanse herself after a bowel movement. Which of the following should the nurse do to show respect for the woman's cultural and religious beliefs?

Correct Answer: B

Rationale: In Islamic culture, hygiene after defecation is important, and female clients may prefer assistance from female family members (
B) to maintain modesty. The left hand (
A) is traditionally used by the client, not the nurse. Gloves (
C) are standard but not cultural. The husband (
D) may not be appropriate due to modesty.

Question 3 of 5

A client taking the drug disulfiram (Antabuse) is admitted to the ER. Which clinical manifestations are most indicative of recent alcohol ingestion?

Correct Answer: A

Rationale: Disulfiram causes a severe reaction with alcohol, including vomiting, tachycardia (HR 120), and chest pain due to acetaldehyde accumulation, making these symptoms most indicative.

Question 4 of 5

While reviewing the chart of a client with a history of hepatitis B, the nurse finds a serologic marker of HBsAg. The nurse recognizes that the client:

Correct Answer: A

Rationale: Presence of HBsAg indicates active hepatitis B infection, either acute or chronic, and potential infectivity.

Question 5 of 5

A client is scheduled for knee replacement surgery, and the nurse is reviewing preoperative laboratory results. The nurse should notify the physician about which of the following abnormal laboratory results?

Correct Answer: A

Rationale: A platelet count of 119,000 (
A) is below the normal range (150,000-450,000), increasing bleeding risk during surgery, and should be reported. Glucose 83 (
B), hemoglobin 13.7 (
C), and sodium 141 (
D) are within normal limits.

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