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Questions 149

NCLEX-RN

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Extract:


Question 1 of 5

A post-operative client with an abdominal wound tries to reach over and take a book off the bedside table. He immediately screams and calls for the nurse. The nurse notices serosanguineous drainage coming from the incision on the abdomen. The first action the nurse should take is to

Correct Answer: A

Rationale: Covering the incision with a sterile dressing prevents contamination and infection, which is the immediate priority. Assessing vitals or notifying the surgeon follows after stabilizing the wound.

Question 2 of 5

The nurse is assessing a client who is 36 hours postpartum. Which of the following findings would indicate a need for further evaluation?

Correct Answer: D

Rationale: a temperature of 100.4°F may indicate infection, such as endometritis, and requires further evaluation

Question 3 of 5

A woman is admitted to the labor and delivery unit in a sickle cell crisis. Which of the following nursing actions is the HIGHEST priority?

Correct Answer: C

Rationale: adequate hydration is a priority for any client with sickle cell crisis

Question 4 of 5

Which of the following roommates would be most suitable for the client with myasthenia gravis?

Correct Answer: A

Rationale: Hypothyroidism poses no infection risk, unlike pyelonephritis or bronchitis.

Question 5 of 5

The nurse is suspected of charting medication administration that he did not give. The nurse can be charged with:

Correct Answer: A

Rationale: Falsifying medical records, such as charting unadministered medications, constitutes fraud.

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