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Questions 148

NCLEX-RN

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Question 1 of 5

A woman is receiving outpatient treatment at a mental health center. She starts crying and tells the nurse her husband has filed for divorce. The best response from the nurse is

Correct Answer: D

Rationale: An open-ended response like 'Tell me what happened' encourages the client to express feelings, fostering therapeutic communication.

Question 2 of 5

The nurse is caring for a 70-year-old client with hypovolemia who is receiving a blood transfusion. Assessment findings reveal crackles on chest auscultation and distended neck veins. What is the nurse's initial action?

Correct Answer: A

Rationale: Crackles and distended neck veins suggest fluid overload from the transfusion. Slowing the transfusion reduces further overload while maintaining access. Stopping it entirely or documenting only delays intervention.

Question 3 of 5

The nurse is caring for a client whose native language is Korean; he speaks only a few words of English. The health care provider has determined that the client needs to undergo a coronary artery bypass graft. Which is the appropriate action by the nurse?

Correct Answer: D

Rationale: A licensed translator ensures accurate communication and informed consent, adhering to ethical and legal standards.

Question 4 of 5

What is the responsibility of the nurse in obtaining an informed consent for surgery?

Correct Answer: D

Rationale: The nurse's role is to witness the client's signature and ensure the consent form is completed, not to explain the procedure.

Question 5 of 5

The nurse is teaching a client with limited mobility about preventing blood clots. Which statement by the nurse is correct?

Correct Answer: A

Rationale: Crossing legs can impede venous return, increasing clot risk, so avoiding this is correct. Long car rides are a risk but not limited to two hours, and pillows under knees can worsen circulation.

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