Questions 150

NCLEX-RN

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Question 1 of 5

The nurse is caring for a client who has just undergone a liver biopsy. Which of the following interventions is most important in the immediate post-procedure period?

Correct Answer: A

Rationale: Keeping the client on the right side for 2 hours post-liver biopsy applies pressure to the site, reducing the risk of bleeding.

Question 2 of 5

Which of the following is a commonality that is shared in terms of both restraints and urinary catheters?

Correct Answer: A

Rationale: Both restraints and urinary catheters can lead to infections restraints via skin breakdown and catheters via urinary tract infections if not properly managed.

Question 3 of 5

The client received electroconvulsive therapy (ECT) an hour ago and tells the nurse that he has a headache. Which response by the nurse is best?

Correct Answer: B

Rationale: Offering acetaminophen addresses the client's complaint directly and safely, as headaches are a common side effect of ECT. Informing the client that headaches are common does not provide relief, and a nap or unclear commands are not appropriate responses.

Question 4 of 5

A client has received electroconvulsive therapy (ECT). What intervention should the nurse perform first in the posttreatment area and upon the client's awakening?

Correct Answer: B

Rationale: The nurse should first monitor vital signs, orient the client, and review with the client that he or she just received an ECT treatment. The posttreatment area should include accessibility to the anesthesia staff, oxygen, suction, pulse oximeter, vital sign monitoring, and emergency equipment. The nursing interventions outlined in the remaining options will follow accordingly.

Question 5 of 5

A client with a history of migraine headaches is prescribed sumatriptan (Imitrex). The nurse should instruct the client to:

Correct Answer: A

Rationale: Sumatriptan is most effective when taken at the onset of a migraine to abort the attack.

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