NCLEX Questions, NCLEX Trainer Test 4 Questions, NCLEX-PN Questions, Nurselytic

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Question 1 of 5

The nurse is caring for a client who is receiving IV fluids at 125 mL/hour. Which of the following findings should the nurse report immediately?

Correct Answer: C

Rationale: Shortness of breath and crackles suggest fluid overload, a serious complication. Options A, B, and D are normal.

Question 2 of 5

The nurse is caring for a 14 month-old just diagnosed with cystic fibrosis. The parents state this is the first child in either family with this disease, and ask about the risk to future children. What is the best response by the nurse?

Correct Answer: B

Rationale: 1 in 4 risk for each child to have the disease. Cystic fibrosis is autosomal recessive, with a 25% chance of the disease per pregnancy if both parents are carriers.

Question 3 of 5

The nurse is preparing a client with a severe case of inflamed hemorrhoids for a rectal examination by the physician. What is the best position to place her in on the examination table?

Correct Answer: B

Rationale: The knee-chest position provides optimal exposure for rectal examination, minimizing discomfort with inflamed hemorrhoids.

Question 4 of 5

An adult is admitted to the nursing care unit. He begs the nurse to give him a laxative. Which data in the admission assessment contraindicates administration of a laxative?

Correct Answer: D

Rationale: Right lower quadrant pain may indicate appendicitis or other acute conditions; laxatives could worsen the condition, risking perforation. Two days without a bowel movement, mild fever, or nausea do not contraindicate laxatives.

Question 5 of 5

The doctor has ordered the removal of a Davol drain. Which of the following instructions should the nurse give to the client prior to removing the drain?

Correct Answer: C

Rationale: Holding the breath during Davol drain removal prevents air entry into the wound. Normal breathing , deep breaths , or slow breathing may increase complications.

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