NCLEX Questions, ATI NCLEX-RN Practice Questions Questions, NCLEX-RN Questions, Nurselytic

Questions 158

NCLEX-RN

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Question 1 of 5

The nurse is caring for a client with a diagnosis of ectopic pregnancy. Which diagnostic test is most likely to be ordered?

Correct Answer: C

Rationale: Ultrasound confirms the location of the pregnancy (e.g. outside the uterus) and serial serum hCG levels help diagnose ectopic pregnancy by showing abnormal doubling patterns. Both tests are commonly ordered.

Question 2 of 5

A nurse is assisting the physician with chest tube removal. Which client instruction is appropriate during removal of the tube?

Correct Answer: A

Rationale: Taking a deep breath or humming (Valsalva maneuver) during chest tube removal increases intrathoracic pressure, preventing air entry. Holding breath for two minutes (
B) is excessive, exhaling (
C) risks pneumothorax, and deep breathing (
D) is unsafe.

Question 3 of 5

In assessing a person after experiencing spousal abuse, which need has the highest priority?

Correct Answer: C

Rationale: Assessing the level of anxiety, coping responses, and support systems is very important, but not of highest priority at this time. A history of physical abuse is an important part of assessment. The nurses must also always ask if there is abuse of the children. Although all of these answers are very important in assessment, the highest priority is assessment of suicide potential, because this could cause the greatest harm to the client. Feeling there is no other way out, abused spouses may consider suicide. The spouse may be self-medicating herself with alcohol or drugs to escape an awful situation. The abuser may also be abusing drugs or alcohol. If this is so, the nurse should encourage the spouse to seek counseling and not to return to the home.

Question 4 of 5

A client with a history of endometriosis is admitted with complaints of pelvic pain. The nurse should expect the client to have:

Correct Answer: A

Rationale: Endometriosis causes pelvic pain and dysmenorrhea due to ectopic endometrial tissue responding to hormonal changes.

Question 5 of 5

The client is prescribed albuterol (Proventil) for asthma. Which side effect should the nurse monitor for?

Correct Answer: B

Rationale: Albuterol, a beta-agonist, stimulates the sympathetic nervous system, causing tremors as a common side effect. Tachycardia (not bradycardia), hypertension, and diarrhea are more likely than hypotension or constipation.

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