NCLEX Questions, NCLEX Trainer Test 6 Questions, NCLEX-PN Questions, Nurselytic

Questions 156

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Extract:

A patient 48 hours after surgery for a hernia repair.


Question 1 of 5

The nurse checks the incision of a patient 48 hours after surgery for a hernia repair. Which of the following findings would indicate a possible complication?

Correct Answer: C

Rationale: Strategy: Determine the significance of each answer choice. (1) slight swelling is expected during healing (2) slight crusting of incision line is normal (3) correct-should be pink, not red, indicates possible infection, other signs include increased warmth, tenderness, pain, and purulent or odorous drainage (4) shows healing is taking place

Extract:


Question 2 of 5

The nurse is caring for a client who is receiving IV fluids at 100 mL/hour. Which of the following findings would be of GREATest concern to the nurse?

Correct Answer: C

Rationale: Shortness of breath and crackles suggest fluid overload, a serious complication of IV fluids, potentially leading to pulmonary edema. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 80 bpm, and urine output 50 mL/hour indicate stability.

Extract:

A male client is admitted with urinary tract problems. A prostate-specific antigen (PSA) and acid phosphatase Test are to be done.


Question 3 of 5

The nurse knows that

Correct Answer: A

Rationale: Strategy: Think about each answer choice. (1) correct-PSA Test has replaced acid phosphatase Test in screening for prostatic cancer; Test must be drawn before digital rectal exam, as manipulation of the prostate will abnormally increase PSA value (2) inaccurate information about a PSA (3) inaccurate information about a PSA (4) inaccurate information about a PSA

Extract:

A client displaying the following symptoms: elevated vital signs, hallucinations, and aggressive behavior. The client's friend says she thinks that he has been using hallucinogenic drugs.


Question 4 of 5

The appropriate nursing action would be to

Correct Answer: B

Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) unnecessary at this time (2) correct-symptoms will subside with time and decreased stimulation (3) unnecessary at this time (4) inappropriate

Extract:


Question 5 of 5

Which of the following findings is consistent with a diagnosis of congestive heart failure?

Correct Answer: A

Rationale: Jugular vein distention reflects increased fluid volume and right-sided heart failure, a hallmark of congestive heart failure. Other options are not specific to this condition.

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