Questions 151

NCLEX-RN

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Extract:


Question 1 of 5

The nurse is planning preoperative teaching with a client scheduled for a transurethral resection of the prostate (TURP). Which most frequent cause of postoperative pain should the nurse plan to include in the discussion?

Correct Answer: A

Rationale: Bladder spasms can occur after this surgery because of postoperative bladder distention or irritation from the balloon on the indwelling urinary catheter. The nurse administers antispasmodic medications as prescribed to treat this type of pain. Options 2 and 3 are not frequent causes of pain. Some surgeons purposefully apply tension to the catheter for a few hours postoperatively to control bleeding. There is no incision with a TURP.

Question 2 of 5

The nurse is caring for a client with a closed head injury. Which finding indicates increasing intracranial pressure?

Correct Answer: A

Rationale: Widening pulse pressure (e.g., increasing systolic with stable diastolic) is a sign of increasing intracranial pressure, part of Cushing's triad.

Question 3 of 5

The nurse is assessing a client with suspected appendicitis. Which of the following findings would support this diagnosis?

Correct Answer: A, B

Rationale: Pain at McBurney's point and decreased bowel sounds are classic signs of appendicitis due to peritoneal irritation and intestinal obstruction.

Question 4 of 5

The nurse is caring for a client who is receiving mechanical ventilation. Which of the following actions is the highest priority to prevent ventilator-associated pneumonia?

Correct Answer: B

Rationale: Elevating the head of the bed to 30-45 degrees reduces the risk of aspiration, a key factor in preventing ventilator-associated pneumonia.

Question 5 of 5

The nurse is teaching a client with a new diagnosis of gout about medication management. Which of the following medications should the client expect to take during an acute attack?

Correct Answer: A

Rationale: Colchicine is used to relieve inflammation during an acute gout attack.

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