Questions 151

NCLEX-RN

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Question 1 of 5

The nurse is involved in preoperative teaching with a client who will be undergoing a lung resection. The client is told that two chest tubes will be placed during surgery. The nurse explains that the purpose of the nurse is to:

Correct Answer: B, C

Rationale: Chest tubes are placed to remove air (pneumothorax) and fluid (hemothorax or pleural effusion) from the pleural space to restore negative pressure and lung expansion. Preventing clots or milking tubes is not their primary purpose.

Question 2 of 5

The nurse should inform a client taking carbamazepine (Tegretol) that it can affect other medications in which of the following ways?

Correct Answer: A

Rationale: Carbamazepine induces liver enzymes, reducing the effects of oral anticoagulants like warfarin by increasing their metabolism. It does not typically affect verapamil, other anticonvulsants, or contraceptives in the ways described.

Question 3 of 5

The nurse is performing Leopold’s maneuvers on a woman who is in her eighth month of pregnancy. The nurse is palpating the uterus as shown below. Which of the following maneuvers is the nurse performing?

Question Image

Correct Answer: C

Rationale: The third maneuver is used to identify the presenting part. This maneuver is used to identify the part of the fetus that lies over the inlet to the pelvis. While facing the client, the nurse places the tips of the fi rst three fi ngers on the side of the woman’s abdomen above the symphysis pubis and palpates deeply around the presenting part to identify its contour and size. The first maneuver involves using the tips of the fi ngers of both hands to palpate the uterine fundus. The second maneuver identifi es the back of the fetus, and the fourth maneuver identifies the cephalic prominence

Question 4 of 5

A client with a new colostomy asks the nurse how to prevent skin irritation around the stoma. What is the best response by the nurse?

Correct Answer: C

Rationale: A snug-fitting skin barrier and cleaning with mild soap prevent skin irritation by protecting the peristomal skin and maintaining hygiene without causing trauma.

Question 5 of 5

An expected physiologic response to a low potassium level is:

Correct Answer: A

Rationale: Hypokalemia can cause cardiac dysrhythmias due to its effect on cardiac muscle excitability, making it the most significant physiologic response.

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