NCLEX-RN
RN NCLEX Next Gen Questions Questions
Extract:
Question 1 of 5
The nurse is monitoring a client who is receiving a blood transfusion when the client reports diaphoresis, warmth, and a backache. The nurse should take which actions? Select all that apply.
Correct Answer: B,C,D,E
Rationale: If a client experiences diaphoresis, warmth, and a backache, a transfusion reaction is suspected. The nurse stops the transfusion and prevents the infusion of any additional blood; then the nurse hangs a bag of 0.9% sodium chloride solution. This maintains IV access and helps maintain the client's intravascular volume. The primary health care provider is notified, as is the blood bank. The nurse also documents the occurrence, the actions taken, and the client's response.
To preserve the IV access, the nurse should not remove the catheter and discontinue the IV site.
Question 2 of 5
Which of the following should the nurse expect to include in the plan of care to ensure adequate nutrition for a very active, talkative, and easily distractible client who is unable to sit through meals?
Correct Answer: B
Rationale: Nutritious finger foods allow the client to eat while accommodating their distractibility and activity level.
Question 3 of 5
A client with a history of epilepsy is prescribed phenobarbital. The nurse should monitor the client for which of the following side effects?
Correct Answer: A
Rationale: Phenobarbital commonly causes drowsiness, which the nurse should monitor in clients with epilepsy.
Question 4 of 5
The nurse is assessing a 55-year-old client with chronic obstructive pulmonary disease. The client weighs 200 lb and is 6 feet tall. Using the diagram shown here, the nurse should record in the health history that the client's chest is:
Correct Answer: A
Rationale: A barrel-shaped chest is characteristic of chronic obstructive pulmonary disease due to hyperinflation of the lungs, which is likely in this client. The client's weight and height suggest a normal body habitus, not a muscular chest, and bronchodilator use does not directly cause this chest shape.
Question 5 of 5
The nurse has conducted a stress management seminar for clients in an ambulatory care setting. Which statement by a client would indicate a need for further teaching?
Correct Answer: C
Rationale: Confrontation is a communication technique, not a stress management technique. It may also exacerbate stress, at least in the short term, rather than alleviate it. Biofeedback, progressive muscle relaxation, meditation, and guided imagery are techniques that the nurse can teach the client to reduce the physical impact of stress on the body and promote a feeling of self-control for the client. Biofeedback entails electronic equipment, whereas the others require no adjuncts, such as tapes, once the technique is learned.