NCLEX Questions, ATI NCLEX-RN Practice Questions Questions, NCLEX-RN Questions, Nurselytic

Questions 158

NCLEX-RN

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Extract:


Question 1 of 5

The nurse is caring for an eight-year-old following a routine tonsillectomy. Which finding should be reported immediately?

Correct Answer: D

Rationale: Respiratory stridor post-tonsillectomy suggests airway obstruction, a life-threatening complication requiring immediate reporting. The other findings are normal or less urgent.

Question 2 of 5

A 28-year-old client performs a long, involved ritual in getting up and preparing for the day. He became unable to get to his job before noon. His family, in desperation, has admitted him to the hospital's psychiatric unit. On the unit, he is always late for breakfast, which is served at 8 am. The nurse identifies that the best approach to this problem is to:

Correct Answer: C

Rationale:
To interfere with the ritual will increase anxiety. Arranging the schedule to allow completion of the ritual before essential activities like breakfast accommodates the client's needs while addressing the issue.

Question 3 of 5

A client is scheduled for a magnetic resonance imaging (MRI) to locate a cerebral lesion. It is important for the nurse to find out if he has a(n):

Correct Answer: C

Rationale: Iodine is not used as a contrast medium for MRI. It is important to inquire about allergy to seafood if the client is to have an arteriogram or enhanced computer tomography. MRI is safe if seizures are under control. It is more important to inquire about movable metal implants. Clients with movable metal implants such as shrapnel or aneurysm clips or clients with permanent pacemakers or implanted pumps can be traumatized during an MRI. Nonmovable metal prostheses or hardware will not cause trauma during an MRI.

Question 4 of 5

The client at 38 weeks gestation is admitted with a blood pressure of 150/100,proteinuria and edema. The nurse should prepare to administer which of the following medications?

Correct Answer: A

Rationale: The client’s symptoms (hypertension proteinuria edema) indicate preeclampsia. Magnesium sulfate is administered to prevent seizures (eclampsia). Terbutaline is a tocolytic hydralazine treats hypertension and betamethasone is for fetal lung maturity in preterm labor.

Question 5 of 5

A 40-year-old client has been admitted to the hospital with severe substernal chest pain radiating down his left arm. The nurse caring for the client establishes the following priority nursing diagnosis--Alteration in comfort, pain related to:

Correct Answer: A

Rationale: Anaerobic metabolism results because the decreased blood supply to the myocardium causes a release of lactic acid. Lactic acid is an irritant to the myocardial neural receptors, producing chest pain. Chest pain is caused by a decrease in the O2 supply to the myocardial cells. Treatment modalities for chest pain are aimed toward increasing the blood flow through coronary arteries. Chest pain causes an increase in the stimulation of the sympathetic nervous system. This stimulation increases the heart rate and blood pressure, causing an increase in myocardial workload aggravating the chest pain. Chest pain and anxiety cause increased secretion of catecholamines by stimulating the sympathetic nervous system. This stimulation increases chest pain by increasing the workload of the heart.

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