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Questions 164

NCLEX-PN

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Question 1 of 5

The nurse is caring for a client with Cushing's syndrome. The nurse should carefully assess the client for signs of:

Correct Answer: B

Rationale: Cushing's syndrome causes immunosuppression, increasing infection risk . Hypoglycemia , hypovolemia , and hyperinsulinemia are not primary concerns.

Question 2 of 5

The nurse is caring for a bedridden client experiencing fecal incontinence. Which nursing intervention is the highest priority for this client?

Correct Answer: C

Rationale: Perianal skin care with barrier cream prevents skin breakdown, a common complication of fecal incontinence. Wound care consultation follows if breakdown occurs. Rectal tubes risk complications, and briefs may trap moisture, worsening irritation.

Question 3 of 5

The licensed practical nurse (LPN) assigns the ambulation of a client to unlicensed assistive personnel (UAP). The LPN observes UAP placing the clients Foley bag on the IV pole at the level of the client's chest during client ambulation down the length of the hallway. What action should the LPN take initially?

Correct Answer: A

Rationale: The Foley bag must be kept below bladder level to prevent urine backflow and infection risk. Immediate correction and private education ensure safety and learning without delay.

Question 4 of 5

The nurse in an ambulatory care center is reinforcing teaching to a client with a diagnosis of persistent depressive disorder (dysthymia) about the appropriate use of bupropion hydrochloride sustained release. What statement by the client indicates a need for further teaching?

Correct Answer: B

Rationale: Bupropion sustained-release tablets must not be cut, as this disrupts the controlled-release mechanism, risking side effects. Other statements are correct: mood changes require reporting, missed doses shouldn't be doubled, and therapeutic effects take weeks.

Question 5 of 5

A nurse is caring for a client who had a vaginal birth 2 hours ago. The nurse notes that the client's perineal pad is saturated with blood 20 minutes after placing a new pad. The client's fundus is boggy, palpable above the level of the umbilicus, and deviated to the right. Which intervention should the nurse perform first?

Correct Answer: C

Rationale: A boggy, deviated fundus and heavy bleeding suggest uterine atony and possible bladder distension preventing uterine contraction. Assisting to void relieves bladder pressure, promoting uterine involution. Oxytocin follows if bleeding persists.

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