NCLEX Questions, RN NCLEX Practice Test Questions, NCLEX-RN Questions, Nurselytic

Questions 158

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Question 1 of 5

A young child has been placed in a spica cast. The chief concern of the nurse during the first few hours is:

Correct Answer: A

Rationale: Because the extremity may continue to swell and the cast could constrict circulation, the nurse should elevate the limb and observe for capillary refill, warmth, mobility of toes and circulation. Although muscle tone may diminish over time in the affected limb, this is not the immediate concern. The limb has been immobilized already by the cast, and therefore immobilization is not a concern. Heated fans and dryers are discouraged because the outside cast will dry quickly, yet the area beneath the cast remains wet and could cause burns.

Question 2 of 5

The nurse knows that children are more susceptible to respiratory tract infections owing to physiological differences. These childhood differences, adverts an adult, include:

Correct Answer: D

Rationale: Although a child has fewer alveoli than an adult, the child's respiratory rate is faster. Although a child may use diaphragmatic breathing, the adult exchanges a larger volume of air. The adult has a larger number of alveoli than a child. The child's chest is rounded whereas the adult chest is more of an oval shape, and the child does exchange a smaller volume of air than an adult.

Question 3 of 5

A 30-year-old client in the third trimester of her pregnancy asks the nurse for advice about upper respiratory discomforts. She complains of nasal stuffiness and epistaxis, most noticeable on the left side. Which reply by the nurse is correct?

Correct Answer: C

Rationale: Decongestants may exaggerate the nasal stuffiness associated with pregnancy. Judicious use of decongestants and nasal sprays is advocated during pregnancy. Cool air vaporizers and saline drops may help to relieve the nasal stuffiness. Positioning on either lateral side does not decrease nasal stuffiness or prevent epistaxis. Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation, which contributes to epistaxis. The nurse may recommend cool air vaporizers and saline drops to help with the nasal stuffiness. Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation discomforts associated with pregnancy.

Question 4 of 5

A client with sickle cell disease is admitted in active labor. Which nursing intervention would be most helpful in preventing a sickling crisis?

Correct Answer: D

Rationale: IV fluids at 200 mL/hr prevent dehydration, a trigger for sickling crises, by maintaining hydration and blood flow. BP monitoring (
A), pain medication (
B), and ABGs (
C) are supportive but less directly preventive.

Question 5 of 5

A female client presents to the obstetric-gynecology clinic for a pregnancy test, the result which turns out to be positive. Her last menstrual period began December 10, 1993. Using Nägele's rule, the nurse estimates her date of delivery to be:

Correct Answer: A

Rationale: According to Nägele's rule, the estimated date of delivery is calculated by adding 7 days to the date of the first day of the normal menstrual period (December 10 + 7 days = December 17), and then by counting back 3 months (December 17 - 3 mo = September 17). (B, C,
D) These answers are incorrect.

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