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Questions 158

NCLEX-RN

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Extract:


Question 1 of 5

In preparation for the removal of the client's chest tubes, the nurse should instruct the client to:

Correct Answer: B

Rationale: During chest tube removal, the client should hold their breath and bear down (Valsalva maneuver) to increase intrathoracic pressure, reducing the risk of air entering the pleural space.

Question 2 of 5

Which nursing implication is appropriate for a client undergoing a paracentesis?

Correct Answer: A

Rationale: A full bladder impedes ascitic fluid withdrawal during paracentesis, so the client should void beforehand.

Question 3 of 5

A male client has been an insulin-dependent diabetic for approximately 30 years. He frequently indulges in high-sugar foods and forgets to take his insulin. He has not experienced acute diabetic emergencies over the years but is now beginning to demonstrate symptoms of diabetic peripheral neuropathy. This distresses him because dancing is one of his favorite pastimes. He decides to question his wife's home health nurse about diabetic peripheral neuropathy. The nurse points out his noncompliance to his diabetic diet and insulin regimen. The client answers the nurse, 'It has been my experience that the diabetic diet is very difficult to follow. As far as the insulin, isn't a fellow allowed to forget now and then?' The client's actions and response best demonstrate:

Correct Answer: C

Rationale: Depression may be an underlying feature, but it is not evident from limited data presented here. Anger is not exhibited in his response. Denial is evident in the client's actions; through the years, he has had a casual approach to his illness. He only becomes concerned when bodily changes affect his present lifestyle, when in fact he should have been concerned all along. His verbal response also reflects denial. There is no evidence of bargaining in the client's actions or verbal response.

Question 4 of 5

Priapism may be a sign of:

Correct Answer: A

Rationale: Priapism in the trauma client is due to the neurological dysfunction seen in spinal cord injury. Priapism is an abnormal erection of the penis; it may be accompanied by pain and tenderness. This may disappear as spinal cord edema is relieved. It is not associated with death, urinary incontinence, or reproductive dysfunction as a primary issue.

Question 5 of 5

Which clients can be assigned to share a room in the emergency department during a disaster?

Correct Answer: B

Rationale: A pregnant client and a client with a fractured arm have stable non-infectious conditions suitable for sharing a room. The other pairs include clients with unstable (cyanosis abdominal wound chest pain) or infectious (MRS
A) conditions or psychiatric issues requiring isolation.

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