NCLEX Questions, NCLEX Trainer Test 10 Questions, NCLEX-PN Questions, Nurselytic

Questions 227

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Question 1 of 5

The nurse is caring for a client who is receiving IV fluids at 150 mL/hour. Which of the following findings would be of GREATest concern to the nurse?

Correct Answer: C

Rationale: Crackles in the lung bases suggest fluid overload, a serious complication of IV fluids, potentially leading to pulmonary edema. Options A, B, and D are normal or less concerning: blood pressure 140/90 mmHg and heart rate 90 bpm are stable, and urine output 100 mL/hour is adequate.

Question 2 of 5

A nurse is the first on the scene of a motor vehicle accident. The victim has sucking sounds with respirations at a chest wound site and tracheal deviation toward the uninjured side. Until others arrive, the priority nursing action would be to

Correct Answer: A

Rationale: implementation, in an open pneumothorax, air enters the pleural cavity through an open wound; placing a sterile dressing loosely over the wound allows air to escape but not reenter the pleural space

Question 3 of 5

The nurse assesses a prolonged deceleration of the fetal heart rate while the client is receiving oxytocin IV to stimulate labor. The priority nursing intervention would be to

Correct Answer: A

Rationale: will decrease contractions and thus possibly remove uterine pressure to the fetus, which is possibly cause of deceleration

Question 4 of 5

The nurse is teaching a client with a new diagnosis of heart failure about carvedilol (Coreg). Which of the following statements by the client indicates a need for further teaching?

Correct Answer: D

Rationale: Stopping carvedilol when feeling better is incorrect, as heart failure requires lifelong treatment to manage symptoms and prevent progression. Options A, B, and C are correct: food reduces GI upset, pulse monitoring detects bradycardia, and dizziness may indicate hypotension.

Question 5 of 5

The nurse is caring for a client in the ICU. Hemodynamic monitoring is accomplished via a Swan-Ganz catheter. The nurse is aware that this type of monitoring will provide which of the following information?

Correct Answer: B

Rationale: CVP readings measure the pressure in the right ventricle, the Swan-Ganz catheter measures the pulmonary artery wedge pressure, which is an indirect reading of the pressure in the left ventricle

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