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Questions 164

NCLEX-PN

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Question 1 of 5

As adult is admitted with bleeding esophageal varices, and a triple-lumen nasogastric tube is inserted and the balloons inflated. What should the nurse keep at the bedside because the client has this tube?

Correct Answer: C

Rationale: Scissors are kept at the bedside to cut and release the tube if the balloons cause airway obstruction or excessive pressure, a critical safety measure for triple-lumen tubes like the Sengstaken-Blakemore.

Question 2 of 5

The nurse is talking with the parents of a 2 year old client about nutritional choices to promote growth and development. The family observes a strict vegan diet. Which of the following information should the nurse include? Select all that apply.

Correct Answer: B,D,E

Rationale: Leafy greens provide calcium, sunlight/mushrooms/fortified milks supply vitamin D, and vitamin C with iron enhances absorption. Legumes alone lack essential amino acids, and vegetables/fruits don't provide B12.

Question 3 of 5

The nurse is preparing to change the wound dressing for a client who is receiving negative pressure wound therapy. Which of the following actions should the nurse take? Select all that apply.

Correct Answer: A,B,C,D,E

Rationale: All actions are correct: pain management , skin protection , proper foam sizing , correct pressure , and leak-free dressing ensure effective therapy.

Question 4 of 5

The nurse is caring for a client who has gastroesophageal reflux disease and has been receiving long-term omeprazole therapy. The nurse should recognize that the client is at highest risk for developing

Correct Answer: D

Rationale: Long-term omeprazole increases risk of C. difficile due to altered gut flora. Jaw necrosis , vision changes , and gait disturbance are not associated.

Question 5 of 5

An 18-month-old child has been placed in Bryant's traction. The nurse knows that the traction is properly applied when:

Correct Answer: C

Rationale: Bryant's traction for infants involves both legs at 90 degrees to the body, with buttocks slightly off the bed (fingers can fit underneath), ensuring proper alignment and traction force.

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