NCLEX Questions, Mock NCLEX RN Exam Questions, NCLEX-RN Questions, Nurselytic

Questions 158

NCLEX-RN

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Question 1 of 5

A physician tells the nurse that he wants to orally intubate a client with a No. 8 endotracheal tube. The finding of normal breath sounds on the right side of the chest and diminished, distant breath sounds on the left side of the chest of a newly intubated client is probably due to:

Correct Answer: C

Rationale: The right mainstem bronchus is most frequently intubated in error because the angle of the right mainstem bronchus is very small as compared with that of the left mainstem bronchus. Because ventilation is only occurring on the right side, the nurse would auscultate diminished and distant breath sounds on the left.

Question 2 of 5

A male client has been hospitalized with congestive heart failure. Medical management of heart failure focuses on improving myocardial contractility. This can be achieved by administering:

Correct Answer: A

Rationale: Digoxin enhances myocardial contractility, improving cardiac output in heart failure.

Question 3 of 5

The nurse is caring for a client with a history of a fractured humerus who is in a sling. The client complains of numbness. The nurse should:

Correct Answer: C

Rationale: Numbness in a slung humerus suggests neurovascular compromise, requiring immediate physician notification. Ice, elevation, and massage are insufficient or contraindicated.

Question 4 of 5

A client reports to the nurse that the voices are practically nonstop and that he needs to leave the hospital immediately to find his girlfriend and kill her. The best verbal response to the client by the nurse at this time is:

Correct Answer: A

Rationale: This response validates the client's experience and presents reality to him. This nontherapeutic response minimizes and dismisses the client's verbalized experience. This response can be interpreted by a paranoid client as a threat, thereby increasing the client's potential for violence and loss of control. This response is also threatening. The client's behavior does not call for restraints because he has not lost control or hurt anyone. If seclusion or restraints were indicated, the nurse should never confront the client alone.

Question 5 of 5

Which one of the following statements is correct when measuring the client for crutches?

Correct Answer: B

Rationale: Proper crutch fitting requires a gap of about three inches (or two to three fingerbreadths) between the crutch top and the axilla to prevent nerve damage. The elbow should flex at about 30°, and crutches extend about 6 inches laterally from the foot.

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