NCLEX Questions, NCLEX Trainer Test 2 Questions, NCLEX-PN Questions, Nurselytic

Questions 157

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Question 1 of 5

The nurse is assessing a pregnant client in her third trimester. The parents are informed that the ultrasound suggests that the baby is small for gestational age (SGA). An earlier ultrasound indicated normal growth. The nurse understands that this change is most likely due to what factor?

Correct Answer: C

Rationale: Maternal hypertension. Pregnancy induced hypertension is a common cause of late pregnancy fetal growth retardation. Vasoconstriction reduces placental exchange of oxygen and nutrients.

Question 2 of 5

The nurse is caring for a man who has severe burns and had a skin graft. What nursing care measure is appropriate at the graft site the day of the graft?

Correct Answer: B

Rationale: Elevating the graft site reduces edema, promoting graft adherence on the first day. Open exposure, exercises, or frequent dressing changes risk graft failure.

Question 3 of 5

The nurse is teaching a client with a new diagnosis of gout about allopurinol (Zyloprim). Which of the following instructions should the nurse include?

Correct Answer: B

Rationale: A skin rash may indicate a hypersensitivity reaction to allopurinol, requiring immediate reporting. Options A, C, and D are incorrect.

Question 4 of 5

The nurse is performing an admission history for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestation alerts the nurse to an adverse effect of this drug?

Correct Answer: A

Rationale: Clopidogrel is an antiplatelet medication that can increase the risk of bleeding, such as epistaxis (nosebleeds). Abdominal distention, nausea, and hyperactivity are not typical adverse effects of clopidogrel, so answers B, C, and D are incorrect.

Question 5 of 5

The nurse is caring for a client who is 6 hours postoperative after an appendectomy. Which of the following findings would be of GREATest concern to the nurse?

Correct Answer: B

Rationale: A temperature of 100.8°F 6 hours post-appendectomy suggests infection, possibly from perforation or abscess, requiring immediate evaluation. Options A, C, and D are expected: heart rate 88 is normal, absent bowel sounds are typical post-surgery, and moderate pain is common.

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