NCLEX Questions, NCLEX RN Practice Questions Quizlet Questions, NCLEX-RN Questions, Nurselytic

Questions 149

NCLEX-RN

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Extract:


Question 1 of 5

The nurse is caring for a client with a closed head injury. Fluid is assessed leaking from the ear. The nurse's first action will be to:

Correct Answer: C

Rationale: Fluid leaking from the ear may indicate cerebrospinal fluid (CSF) leakage, a serious complication. Testing for glucose (positive in CSF) is the first step to confirm the nature of the drainage.

Question 2 of 5

After a train accident, the nurse is assigned to triage the injured. Based upon the triage protocol, which individual should be seen last?

Correct Answer: C

Rationale: Triage prioritizes life-threatening conditions. The 25-year-old with minor injuries (abrasion, swollen ankle) is the least urgent compared to potential cardiac, neurological, or traumatic injuries.

Question 3 of 5

Which of the following diet instructions should be given to the client with recurring urinary tract infections?

Correct Answer: D

Rationale: Cranberry juice acidifies urine, reducing bacterial growth and preventing urinary tract infections.

Question 4 of 5

The nurse is checking the client's central venous pressure. The nurse should place the zero of the manometer at the:

Correct Answer: A

Rationale: The phlebostatic axis (4th intercostal space, mid-axillary line) is the standard reference point for accurate central venous pressure measurement.

Question 5 of 5

After a traumatic accident, the client must have his left arm amputated in an emergency procedure. When the client wakes from anesthesia and sees his arm has been amputated, he becomes extremely distressed. He cries uncontrollably and yells about how angry he is at the doctor. The best therapeutic action from the nurse is

Correct Answer: B

Rationale: Sitting quietly with the client provides emotional support, allowing him to process grief and anger without judgment.

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