NCLEX Questions, NCLEX Trainer Test 4 Questions, NCLEX-PN Questions, Nurselytic

Questions 157

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Extract:


Question 1 of 5

The nurse is evaluating the progress of a client who has had a cerebrovascular accident and realizes there has been limited progress. What should the nurse do?

Correct Answer: B

Rationale: Reassessing goals adjusts the care plan to the client's current abilities, optimizing recovery post-CVA.

Question 2 of 5

The nurse is caring for a woman who is receiving internal radiation for cancer of the cervix. Which nursing action will do most to reduce the risk of radiation exposure to other clients?

Correct Answer: A

Rationale: Keeping the door closed minimizes radiation exposure to others by containing emissions. Bed placement or signs are less effective, and observation doesn't reduce exposure.

Question 3 of 5

Which laboratory result would be expected during the emergent phase of a burn injury?

Correct Answer: A

Rationale: Glucose levels rise as a result of the stress response during the emergent phase. Answers B, C, and D are within normal range. K+ and Na+ would be elevated, whereas albumin would be lowered during the emergent period due to increased permeability.

Extract:

A young female with recent ileostomy due to ulcerative colitis. A middle-aged male with elevated temperature and chronic pancreatitis. A teenager in hypovolemic shock following a crushing injury to the chest. A child with compound fracture of the right femur and massive laceration of the left arm.


Question 4 of 5

The nurse would identify which of the following patients as a likely candidate for developing acute renal failure?

Correct Answer: C

Rationale: Strategy: Determine how each answer choice relates to acute renal failure. (1) usually ileostomy clients do not experience severe hypovolemia, which would lead to renal failure problems (2) this type of infection and inflammation does not lead to acute renal failure (3) correct-common cause of acute renal failure is renal ischemia precipitated by hypovolemia or heart failure (4) femoral fractures are more likely to lead to fat embolism than acute renal failure

Extract:


Question 5 of 5

A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the first nursing action would be to

Correct Answer: B

Rationale: Suction excessive tracheobronchial secretions. Suctioning the copious tracheobronchial secretions present in post-thoracic surgery clients maintains an open airway, which is always the priority nursing intervention.

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