NCLEX Questions, NCLEX RN Nursing Exam Questions, NCLEX-RN Questions, Nurselytic

Questions 158

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NCLEX RN Nursing Exam Questions

Extract:


Question 1 of 5

The nurse is assessing a client with suspected diabetic ketoacidosis. Which finding is most expected?

Correct Answer: A

Rationale: Kussmaul respirations (rapid, deep breathing) are a compensatory mechanism in diabetic ketoacidosis to eliminate excess carbon dioxide and correct acidosis. Hypotension, tachycardia, and clear breath sounds are more common.

Question 2 of 5

Upon admission to the hospital, a client reports having "the worst headache I've ever had." The nurse should give the highest priority to which action?

Correct Answer: C

Rationale: A severe headache may indicate a neurological emergency (e.g., subarachnoid hemorrhage). Neuro checks (
C) assess for deterioration. Pain medication (
A), oxygen (
B), and Foley (
D) are secondary.

Question 3 of 5

Which obstetrical client is most likely to have an infant with respiratory distress syndrome?

Correct Answer: B

Rationale: Maternal diabetes increases the risk of neonatal respiratory distress syndrome due to impaired surfactant production from hyperglycemia. Alcohol, smoking, and hypertension are less directly linked.

Question 4 of 5

A client on the psychiatric unit is threatening other clients and staff,and interventions to distract him have not been successful. What action should the nurse take?

Correct Answer: A

Rationale: Threatening behavior that persists despite de-escalation attempts requires immediate intervention. Calling security ensures safety and PRN medication may help calm the client. The other options are unsafe or ineffective in managing acute agitation.

Question 5 of 5

A 60-year-old diabetic is taking glyburide (Diabeta) 1.25 mg daily to treat Type II diabetes mellitus. Which statement indicates the need for further teaching?

Correct Answer: C

Rationale: Skipping meals, like dinner, can cause hypoglycemia in patients on glyburide, a sulfonylurea that stimulates insulin release. Keeping candy for hypoglycemia, avoiding sun (due to photosensitivity), and wearing ID are correct.

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