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Questions 149

NCLEX-RN

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Question 1 of 5

The nurse is caring for a client with dementia who has pulled out three peripheral IVs. Which intervention by the nurse is the best way to manage this client?

Correct Answer: C

Rationale: Wrapping the IV in gauze hides it from view, reducing the likelihood of the client pulling it out, while being less invasive than restraints or threats.

Question 2 of 5

An elderly client is hospitalized for a transurethral prostatectomy. Which finding should be reported to the doctor immediately?

Correct Answer: B

Rationale: Bright red urine with many clots indicates significant bleeding, a potential emergency post-transurethral prostatectomy, requiring immediate reporting.

Question 3 of 5

The nurse is at the nurses' station charting when a physician comes up and says, 'Since you are already logged into the computer, I need you to look up some labs on a client.' The client is not cared for by this nurse. Which response by the nurse is most appropriate?

Correct Answer: D

Rationale: Accessing a client's lab results without authorization violates HIPAA, as the nurse is not assigned to the client. The charge nurse can ensure proper access.

Question 4 of 5

The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. Which action should receive priority?

Correct Answer: B

Rationale: Applying oxygen is the priority to ensure airway patency and oxygenation in a client with facial and neck burns, which can cause airway compromise.

Question 5 of 5

A client is admitted to the unit 2 hours after an injury with second-degree burns to the face, trunk, and head. The nurse would be most concerned with the client developing what?

Correct Answer: B

Rationale: Laryngeal edema is a critical concern with facial and head burns due to the risk of airway obstruction.

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