NCLEX Questions, NCLEX Trainer Test 3 Questions, NCLEX-PN Questions, Nurselytic

Questions 157

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Question 1 of 5

The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His partner states he fell down the stairs 2 hours ago. The nurse should

Correct Answer: B

Rationale: This client requires immediate evaluation. A delay in treatment could result in further deterioration of his condition and possibly permanent harm. Home care nurses must prioritize interventions based on assessment findings that are in the client's best interest.

Question 2 of 5

A client is admitted to the outpatient oncology unit for his routine chemotherapy transfusion. The client's current lab report is WBC 2,500 mm³, RBC 5.1 ml/mm³, and calcium 5 mEq/L. Based on these assessments, which of the following should be the priority nursing diagnosis?

Correct Answer: B

Rationale: clients with a low WBC count are susceptible to infection

Question 3 of 5

The nurse is caring for a client with a history of HIV/AIDS.

Correct Answer: A

Rationale: A CD4 count of 150 cells/mm³ indicates severe immunosuppression in HIV/AIDS, increasing infection risk and requiring immediate intervention. High viral load is concerning but less urgent, and normal WBC and hemoglobin are unremarkable.

Question 4 of 5

The nurse is caring for a client who is postoperative day 1 after a total hysterectomy. Which of the following findings would be of GREATest concern to the nurse?

Correct Answer: A

Rationale: A temperature of 100.4°F suggests infection, a serious complication post-hysterectomy requiring immediate evaluation. Options B, C, and D are expected: incision pain, minimal vaginal bleeding, and absent bowel sounds are normal on day 1.

Question 5 of 5

The nurse in a long-term care facility wants to help a resident become continent of stools. Which is likely to be most helpful when planning care for the resident? Select all that apply.

Correct Answer: A,C,D

Rationale:
Toileting after meals leverages the gastrocolic reflex, fluids soften stool, and walking stimulates peristalsis, all promoting continence. Limiting fiber, listing foods, or discouraging snacking are less effective or counterproductive.

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