NCLEX Questions, NCLEX Trainer Test 4 Questions, NCLEX-PN Questions, Nurselytic

Questions 157

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Extract:

The nurse is admitting a client to the unit from the postoperative recovery area after abdominal exploratory surgery.


Question 1 of 5

After determining the client's vital signs, which of the following activities should the nurse perform next?

Correct Answer: C

Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) implementation, complete assessment first (2) assessment, determine what is happening to the patient now (3) correct-assessment, dressing should be checked on admission to the room and frequently for the next several hours (4) inappropriate assessment, it is too soon for infection to occur secondary to surgery

Extract:


Question 2 of 5

The nurse is caring for a client with a history of peptic ulcer disease.

Correct Answer: A

Rationale: Avoiding spicy foods and caffeine reduces gastric irritation in peptic ulcer disease. Small, frequent meals are preferred, high-fat foods delay healing, and alcohol exacerbates ulcers.

Question 3 of 5

An adult who was struck by lightning is brought to the emergency department. Which action is of highest priority when the client is brought to the emergency room?

Correct Answer: A

Rationale: Lightning strikes can cause cardiac arrhythmias; obtaining an ECG is the highest priority to detect life-threatening rhythm disturbances. Gases, wounds, and electrolytes are secondary.

Question 4 of 5

A 2 year-old child has just been diagnosed with cystic fibrosis. The child's father asks the nurse 'What is our major concern now, and what will we have to deal with in the future?' Which of the following is the best response?

Correct Answer: C

Rationale: Thin, tenacious secretions from the lungs are a constant struggle in cystic fibrosis. Respiratory issues are the primary concern due to chronic lung complications.

Question 5 of 5

Which of the following assessments by the nurse would indicate that the client is having a possible adverse response to the isoniazid (INH)?

Correct Answer: B

Rationale: Clients receiving INH therapy are at risk for developing drug-induced hepatitis. The appearance of jaundice may indicate that the client has liver damage.

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