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Questions 148

NCLEX-RN

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Extract:


Question 1 of 5

The nurse is caring for a cognitively impaired client who begins to pull at the tape securing his IV site. To prevent the client from removing the IV, the nurse should:

Correct Answer: A

Rationale: Securing the IV with tape out of the client's vision minimizes tampering while avoiding restraints or inappropriate actions.

Question 2 of 5

A client has a chest tube in place with a three-chamber chest drainage system. The nurse notes continuous bubbling in the water seal chamber. This indicates which of the following?

Correct Answer: C

Rationale: Continuous bubbling in the water seal chamber indicates a system air leak (
C), such as a loose connection or hole in the tubing. A pneumothorax (
A) may cause intermittent bubbling, adequate suction (
B) is indicated by bubbling in the suction chamber, and incorrect tube positioning (
D) would not typically cause continuous bubbling.

Question 3 of 5

The nurse is caring for a client who is postoperative day 1 following a total hip replacement. Which of the following positions should the nurse AVOID placing the client in?

Correct Answer: D

Rationale: prone position with legs adducted can cause hip dislocation; abduction is maintained post-hip replacement

Question 4 of 5

The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?

Correct Answer: A

Rationale: Clients with MRSA require contact precautions due to the highly contagious nature of the infection, necessitating a private room to prevent transmission to others.

Question 5 of 5

The primary cause of anemia in a client with chronic renal failure is:

Correct Answer: D

Rationale: Chronic renal failure reduces erythropoietin production by the kidneys, leading to decreased red blood cell production and anemia.

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