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Questions 148

NCLEX-RN

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Extract:


Question 1 of 5

The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40. The initial nurse's action should be to:

Correct Answer: B

Rationale: Hypotension and unresponsiveness suggest hypovolemia or shock, so increasing the normal saline infusion is the initial action to restore volume.

Question 2 of 5

The nurse is caring for a postcholecystectomy client who had the T-tube removed this AM. Two hours after removal of the T-tube, the nurse notes that the 4x4 dressing covering the stab site is saturated with dark, greenish-yellow drainage. It is MOST appropriate for the nurse to take which of the following actions?

Correct Answer: A

Rationale: expected that a stab wound will continue to drain until the wound seals; nurse should keep wound clean and dry

Question 3 of 5

A student nurse is assigned to change a patient's dressing. The soiled bandage is saturated with bright red blood. How should the student nurse dispose of the bandage?

Correct Answer: B

Rationale: Blood-saturated bandages are biohazardous and must be disposed of in a labeled biohazard bag to prevent infection transmission.

Question 4 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.

Question 5 of 5

The nurse is preparing to pull a thin, frail client up in the bed. No one responds to the nurse's call for lifting assistance. Which is the best action by the nurse?

Correct Answer: C

Rationale: Using the draw sheet to pull the client up is the safest option to prevent injury to both the client and nurse when assistance is unavailable.

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