Questions 151

NCLEX-RN

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Extract:


Question 1 of 5

The nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions is the highest priority to prevent ventilator-associated pneumonia?

Correct Answer: B

Rationale: Elevating the head of the bed to 30-45 degrees reduces the risk of aspiration, a key factor in preventing ventilator-associated pneumonia.

Question 2 of 5

The nurse is discharging a client who has been hospitalized for preterm labor. The client needs further instruction when the nurse is

Correct Answer: A

Rationale: Suspecting a bladder infection requires immediate medical evaluation, not just a visit to the obstetrician, as infections can trigger preterm labor. The other statements reflect correct understanding of preterm labor management.

Question 3 of 5

The nurse is caring for a client post-myocardial infarction. Which activity should the nurse encourage to promote recovery?

Correct Answer: B

Rationale: Light ambulation as tolerated promotes circulation and prevents complications like deep vein thrombosis, while avoiding overexertion post-myocardial infarction.

Question 4 of 5

A client with a history of chronic lymphocytic leukemia is admitted with fatigue. The nurse should monitor the client for which of the following?

Correct Answer: A

Rationale: Chronic lymphocytic leukemia can cause anemia due to bone marrow suppression, leading to fatigue.

Question 5 of 5

A client is scheduled for a creatinine clearance test. Which one of the following preparations is appropriate for the nurse to make?

Correct Answer: A

Rationale: A creatinine clearance test requires a 24-hour urine collection to assess kidney function accurately, making this the appropriate preparation.

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