NCLEX Questions, NCLEX RN Practice Tests Questions, NCLEX-RN Questions, Nurselytic

Questions 149

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Question 1 of 5

The nurse is caring for a client who has stage 3 lung cancer and is in renal failure. The client indicates that he does not wish to have life-sustaining treatment and wants to die a natural death. What document does the nurse anticipate this client completing? Fill in the blank.

Correct Answer: B

Rationale: Living Will (
B) is the correct answer, as it documents a client’s preferences for medical treatment, such as refusing life-sustaining measures, aligning with the client’s wish to die naturally without such interventions.

Question 2 of 5

The nurse is obtaining a history on a 74-year-old client. Which statement made by the client would alert the nurse to a possible fluid and electrolyte imbalance?

Correct Answer: B

Rationale: Frequent laxative use can cause fluid and electrolyte losses (e.g., potassium, sodium), leading to imbalances, unlike the other statements.

Question 3 of 5

The nurse is assessing the laboratory results of a client scheduled to receive phenytoin (Dilantin). The Dilantin level, drawn 2 hours ago, is 30 mcg/mL. What is the appropriate nursing action?

Correct Answer: B

Rationale: A Dilantin level of 30 mcg/mL is above the therapeutic range (10-20 mcg/mL), indicating toxicity risk. The nurse should hold the dose and notify the physician for further orders.

Question 4 of 5

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. The nurse notes that the client has a respiratory rate of 28 breaths per minute, is using accessory muscles, and has oxygen saturation of 88% on 2 L/min of oxygen via nasal cannula. Which of the following actions should the nurse take FIRST?

Correct Answer: C

Rationale: positioning in high Fowler’s facilitates breathing and improves oxygenation immediately; other actions may follow based on further assessment

Question 5 of 5

The nurse is caring for a client following a crushing injury to the chest. Which finding would be most indicative of a tension pneumothorax?

Correct Answer: B

Rationale: Tension pneumothorax causes a mediastinal shift, including tracheal deviation toward the unaffected side due to increased intrathoracic pressure.

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