NCLEX Questions, NCLEX RN Practice Test Free 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 bipolar disorder. The client has been manipulating some of the staff and other clients in order to get her way. Which actions by the nurse are appropriate in managing this client? Select all that apply.

Correct Answer: A,B,C

Rationale: Appropriate actions include reinforcing positive behaviors (
A), setting clear limits (
B), and role-playing (
C) to promote appropriate interactions. Treating as a friend (
D) or giving gifts (E) blurs boundaries and encourages manipulation.

Question 2 of 5

When assessing the urinary output of a client who has had extracorporeal lithotripsy, the nurse can expect to find:

Correct Answer: A

Rationale: Extracorporeal lithotripsy breaks up kidney stones, leading to cherry-red urine from minor bleeding that clears as healing progresses.

Question 3 of 5

The physician has prescribed a Becloforte (beclomethasone) inhaler two puffs twice a day for a client with asthma. The nurse should tell the client to report:

Correct Answer: B

Rationale: A sore throat may indicate oral candidiasis, a side effect of inhaled corticosteroids like beclomethasone.

Question 4 of 5

To ensure safety while administering a nitroglycerine patch, the nurse should:

Correct Answer: A

Rationale: Gloves prevent the nurse from absorbing nitroglycerin, avoiding side effects.

Question 5 of 5

The nurse is assisting a client with a colostomy irrigation. The client is positioned on the toilet and has removed the colostomy pouch, and the irrigation bag is filled with 1000 mL of warm water. Place the following actions (in Roman numerals) in the correct order from first to last

Order the Items

Source Container

Allow 15 to 20 minutes for evacuation and then fold the sleeve, secure it, and leave it in place for 30 to 45 minutes before removing it.
Allow the solution to flow in for 5 to 10 minutes and then clamp the tubing and close the top of the irrigation sleeve.
Apply gloves, lubricate the cone tip, and insert it into the stoma, holding it securely.
Apply the irrigation sleeve over the stoma.
Hang the irrigation solution with the bottom of the bag being 20 inches above the stoma.

Correct Answer: E,D,C,B,A

Rationale: The correct order is: Hang the irrigation solution (V), apply the irrigation sleeve (IV), insert the cone tip (III), allow solution to flow (II), and allow evacuation (I), ensuring proper setup and procedure.

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