NCLEX Questions, NCLEX Practice Test RN Questions, NCLEX-RN Questions, Nurselytic

Questions 158

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Question 1 of 5

The nurse is caring for a newborn with a suspected diaphragmatic hernia. The nurse should:

Correct Answer: D

Rationale: Positioning a newborn with a diaphragmatic hernia on the affected side facilitates lung expansion on the unaffected side, improving respiration. Trendelenburg worsens breathing, and fluids are secondary.

Question 2 of 5

A client with myasthenia gravis is admitted in a cholinergic crisis. Signs of of cholinergic crisis include:

Correct Answer: A

Rationale: Cholinergic crisis, often from excessive anticholinesterase medication, causes parasympathetic overstimulation, leading to decreased blood pressure and constricted pupils.

Question 3 of 5

A client with Pneumocystis jiroveci pneumonia is receiving intravenous Pentam (pentamidine). While administering the medication, the nurse should give priority to checking the client's:

Correct Answer: B

Rationale: Pentamidine can cause hypotension, especially during IV administration, requiring close blood pressure monitoring. Reflexes, urine output, and turgor are less immediate concerns.

Question 4 of 5

The mother of a one-year-old wants to know when she should begin toilet-training her child. The nurse's response is based on the knowledge that sufficient sphincter control for toilet training is present by:

Correct Answer: B

Rationale: Sufficient sphincter control for toilet training typically develops between 18-24 months, when children gain the physical and cognitive ability to control urination and defecation.

Question 5 of 5

An appropriate nursing intervention for the client with borderline personality disorder is:

Correct Answer: A

Rationale: Clients with borderline personality disorder often experience mood instability and are at risk for self-harm or suicide. Observing for signs of depression or suicidal thinking is a priority nursing intervention to ensure safety. Allowing the client to lead group sessions or select a caregiver may reinforce manipulative behaviors, and restricting activity to the unit is not typically therapeutic unless specified for safety.

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