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Questions 148

NCLEX-RN

NCLEX-RN Test Bank

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Extract:


Question 1 of 5

A temporary colostomy is performed on the client with colon cancer. The nurse is aware that the proximal end of a double barrel colostomy:

Correct Answer: C

Rationale: The proximal end of a double-barrel colostomy, which produces stool, is typically on the client's right side.

Question 2 of 5

A client in the prenatal clinic is assessed to have a blood pressure of 180/96. The nurse should give priority to:

Correct Answer: D

Rationale: Severe hypertension (180/96) poses a risk to fetal well-being, prioritizing fetal heart tone assessment.

Question 3 of 5

Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?

Correct Answer: D

Rationale: A bus trip to a museum is a low-exertion activity at sea level, minimizing the risk of hypoxia compared to high-altitude or strenuous activities.

Question 4 of 5

The nurse is preparing the client for surgery. The pre-op medication includes atropine sulfate 0.4 mg, meperidine (Demerol HCl) 50 mg, and promethazine hydrochloride (Phenergan) 25 mg IM. Which action should the nurse do first?

Correct Answer: A

Rationale: Ensuring the surgical permit is signed is the priority to confirm informed consent before administering preoperative medications.

Question 5 of 5

A client has a chest tube in place with a three-chamber chest drainage system. The nurse notes continuous bubbling in the water seal chamber. This indicates which of the following?

Correct Answer: C

Rationale: Continuous bubbling in the water seal chamber indicates a system air leak (
C), such as a loose connection or hole in the tubing. A pneumothorax (
A) may cause intermittent bubbling, adequate suction (
B) is indicated by bubbling in the suction chamber, and incorrect tube positioning (
D) would not typically cause continuous bubbling.

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