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

Questions 149

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Extract:


Question 1 of 5

The nurse has assessed the assigned group of clients. Which client would the nurse identify as being at the greatest risk for alterations in sensory perception?

Correct Answer: B

Rationale: Severe autism often involves sensory processing issues, increasing risk for sensory perception alterations, especially during stressful procedures like surgery.

Question 2 of 5

The nurse caring for a client with a closed head injury obtains an intracranial pressure (ICP) reading of 17 mmHg. The nurse recognizes that:

Correct Answer: A

Rationale: An ICP of 17 mmHg is elevated (normal is 7-15 mmHg), indicating increased intracranial pressure, which requires immediate notification of the physician.

Question 3 of 5

When caring for a client with an anterior cervical discectomy, the nurse should give priority to assessing for post-operative bleeding. The nurse should pay particular attention to:

Correct Answer: D

Rationale: Swelling in the posterior neck may indicate a hematoma, which can compress the airway or spinal cord, a critical post-operative complication.

Question 4 of 5

A client is admitted with suspected pernicious anemia. Which findings support the diagnosis of pernicious anemia?

Correct Answer: C

Rationale: Loss of coordination and position sense are neurological symptoms due to vitamin B12 deficiency in pernicious anemia.

Question 5 of 5

Upon entering the client's room the nurse discovers a dose of amoxicillin at the bedside. Which of the following should the nurse do?

Correct Answer: A

Rationale: Documenting in the medical record and filing an incident report address the medication error and ensure follow-up for patient safety.

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