Questions 151

NCLEX-RN

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Question 1 of 5

The nurse is caring for a client who has just undergone a splenectomy. Which of the following complications should the nurse monitor for in the immediate postoperative period?

Correct Answer: A

Rationale: Splenectomy increases infection risk due to impaired immune function, requiring close monitoring.

Question 2 of 5

Which tool or scale would you use for a focused neurological assessment of your client?

Correct Answer: D

Rationale: The Rancho Los Amigos Scale is used for assessing levels of consciousness and cognitive recovery in patients with brain injuries, ideal for a focused neurological assessment.

Question 3 of 5

The nurse caring for a client with an acute head injury should carefully assess which function as the primary indicator of neurological status?

Correct Answer: D

Rationale: The level of consciousness is the primary indicator of neurological status. An alteration in the level of consciousness occurs before any other changes in neurological signs or vital signs. Vital sign changes occur later.

Question 4 of 5

A client with chronic renal failure is experiencing central nervous system changes caused by uremic toxins. Which nursing intervention would be most appropriate for addressing the changes?

Correct Answer: D

Rationale: Regularly assessing mental status monitors uremic encephalopathy progression, guiding timely interventions in chronic renal failure.

Question 5 of 5

The nurse is caring for a client with a closed head injury. Which finding indicates increasing intracranial pressure?

Correct Answer: A

Rationale: Widening pulse pressure (e.g., increasing systolic with stable diastolic) is a sign of increasing intracranial pressure, part of Cushing's triad.

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