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

Questions 158

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Extract:


Question 1 of 5

The nurse is caring for a 70-year-old client with hypovolemia who is receiving a blood transfusion. Assessment findings reveal crackles on chest auscultation and distended neck veins. What is the nurse's initial action?

Correct Answer: A

Rationale: Crackles and distended neck veins suggest fluid overload from the transfusion. Slowing the transfusion prevents worsening overload. Stopping it (
C) is premature, documenting only (
B) delays intervention, and pupil assessment (
D) is irrelevant.

Question 2 of 5

Other drugs may be ordered to manage a client's ulcerative colitis. Which of the following medications, if ordered, would the nurse question?

Correct Answer: D

Rationale: 6-Mercaptopurine is used for Crohn's disease, not ulcerative colitis, so the nurse should question its order.

Question 3 of 5

The nurse is caring for a client with myasthenia gravis who is having trouble breathing. The nurse would encourage which of the following positions for maximal lung expansion?

Correct Answer: D

Rationale: Sitting or high Fowler’s position maximizes lung expansion by reducing diaphragm pressure in myasthenia gravis. Supine (
A), side-lying (
B), and prone (
C) positions restrict breathing.

Question 4 of 5

The nurse is caring for a client with a history of Parkinson’s disease. The nurse should give priority to:

Correct Answer: A

Rationale: Parkinson’s disease causes bradykinesia and rigidity, increasing fall risk, so monitoring for falls is the priority.

Question 5 of 5

The nurse is teaching a client with type 1 diabetes about insulin administration. The nurse should tell the client to:

Correct Answer: C

Rationale: Rotating injection sites prevents lipodystrophy and ensures consistent insulin absorption, a critical teaching point for type 1 diabetes management.

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