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Questions 158

NCLEX-RN

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Extract:


Question 1 of 5

The nurse is caring for clients on a respiratory unit. Upon receiving the following client reports, which client should be seen first?

Correct Answer: C

Rationale: Edema and neck vein distention in a bronchitis client suggest right heart failure or cor pulmonale, requiring immediate assessment. Emphysema discharge (
A), antibiotics (
B), and abnormal PO2 (
D) are less urgent.

Question 2 of 5

The nurse notes hyperventilation in a client with a thermal injury. She recognizes that this may be a reaction to which of the following medications if applied in large amounts?

Correct Answer: B

Rationale: Mafenide acetate can cause metabolic acidosis, leading to compensatory hyperventilation. The other medications listed do not typically cause this reaction.

Question 3 of 5

A 30-year-old male client is admitted to the psychiatric unit with a diagnosis of bipolar disorder. For the last 2 months, his family describes him as being 'on the move,' sleeping 3-4 hours nightly, spending lots of money, and losing approximately 10 lb. During the initial assessment with the client, the nurse would expect him to exhibit which of the following?

Correct Answer: C

Rationale: During the manic phase of bipolar disorder, clients have short attention spans and may be abusive toward authority figures. Introspection requires focusing and concentration; clients with mania experience flight of ideas, which prevents concentration. Grandiosity and an inflated sense of self-worth are characteristic of this disorder. Feelings of helplessness and hopelessness are symptoms of the depressive stage of bipolar disorder.

Question 4 of 5

Which measure helps reduce nipple soreness associated with breastfeeding?

Correct Answer: B

Rationale: Breaking suction by placing a finger between the baby’s mouth and the breast prevents trauma to the nipple, reducing soreness. Feeding early promotes latch but doesn’t address soreness directly, warm soaks may increase inflammation, and a bra supports but doesn’t prevent nipple trauma.

Question 5 of 5

Morphine sulfate 4 mg IV push q2h prn for chest pain was ordered for a client in the emergency room with severe chest pain. The nurse administering the morphine sulfate knows which of the following therapeutic actions is related to the morphine sulfate?

Correct Answer: C

Rationale: Morphine sulfate, a narcotic analgesic, causes sedation and a decrease in level of consciousness. The side effects of morphine sulfate include respiratory depression. Morphine sulfate causes peripheral vasodilation, which decreases afterload, producing a decrease in the myocardial workload. Morphine sulfate alters the perception of pain through an unclear mechanism. This alteration promotes pain relief.

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