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

Questions 158

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Question 1 of 5

On a mother's 2nd postpartum day after having a vaginal delivery, the RN is preparing to assess her perineum and anus as part of her daily assessment. The best position for the client to be placed in for this assessment is:

Correct Answer: A

Rationale: The Sims' position allows optimal exposure of the perineum and anus for assessment by raising the upper buttocks.

Question 2 of 5

The nurse is assessing a client with suspected anaphylactic shock. Which intervention is the priority?

Correct Answer: A

Rationale: Epinephrine is the priority in anaphylactic shock to reverse bronchoconstriction and hypotension. IV fluids and oxygen are secondary, and Trendelenburg is not recommended.

Question 3 of 5

A client is a victim of domestic violence. She is now receiving assistance at a shelter for battered women. She tells the nurse about the cycle of violence that she has been experiencing in her relationship with her husband of 5 years. In the 'tension-building phase,' the nurse might expect the client to describe which of the following?

Correct Answer: C

Rationale: This description is characteristic of the 'tension-building' phase prior to the volatile discharge of tension found in the battering phase.

Question 4 of 5

The physician has ordered an injection of RhoGam for a client with blood type A negative. The nurse knows that RhoGam is given at:

Correct Answer: B

Rationale: RhoGam is administered intramuscularly, typically in the deltoid muscle, for Rh-negative mothers to prevent sensitization. The other locations are incorrect for IM injections of RhoGam.

Question 5 of 5

The physician has scheduled a Whipple procedure for a client with pancreatic cancer. The nurse recognizes that the client's cancer is located in:

Correct Answer: B

Rationale: The Whipple procedure (pancreaticoduodenectomy) is performed for cancer in the head of the pancreas, removing the head, duodenum, and other structures. Tail or body cancers require different surgeries.

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