Questions 150

NCLEX-RN

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Extract:


Question 1 of 5

The nurse is caring for a client with a history of peptic ulcer disease who is experiencing hematemesis. Which of the following interventions is the highest priority?

Correct Answer: B

Rationale: Inserting a nasogastric tube is the priority to assess and manage active bleeding in hematemesis.

Question 2 of 5

A client who had transurethral resection of the prostate complains of dribbling urine after his Foley catheter is removed on the second postoperative day. The nurse notes that the client had $200 \mathrm{~mL}$ of urine output in the last 8 hours with a $1,000 \mathrm{~mL}$ intake. Which of the following interventions is a priority for the nurse at this time?

Correct Answer: B

Rationale: Low urine output and dribbling post-TURP suggest possible bladder distention, which requires immediate assessment to prevent complications. Other interventions may follow based on findings.

Question 3 of 5

When suctioning the respiratory tract of a client, it is recommended that the suctioning period not exceed how many seconds?

Correct Answer: C

Rationale: Suctioning should not exceed 15 seconds to prevent hypoxia and trauma to the airway.

Question 4 of 5

The nurse is caring for a client with a history of peptic ulcer disease who is experiencing hematemesis. Which of the following interventions is the highest priority?

Correct Answer: B

Rationale: Inserting a nasogastric tube is the priority to assess and manage active bleeding in hematemesis.

Question 5 of 5

The nurse is caring for a client who has just undergone a mastectomy. Which of the following interventions is most important in the immediate postoperative period?

Correct Answer: A

Rationale: Encouraging arm exercises prevents lymphedema and promotes circulation post-mastectomy.

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