NCLEX Questions, NCLEX Practice Questions PN Questions, NCLEX-PN Questions, Nurselytic

Questions 176

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Extract:


Question 1 of 5

The nurse should consider which of the following client reports as an indication of an allergic reaction?

Correct Answer: D

Rationale: Lip swelling (
D) indicates an allergic reaction to food. Broccoli/cabbage (
A) affects warfarin's efficacy, headaches (
B) are a side effect of nitroglycerin, and swelling (
C) is a side effect of felodipine.

Question 2 of 5

The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure?

Correct Answer: C

Rationale: Encourage range of motion and ambulation. Mobility reduces the risk of deep vein thrombosis in the post-surgical client and the adult at risk due to other factors.

Question 3 of 5

A client who received complete thickness burns at 7:30 a.m. was rushed to the emergency room where IV therapy with Lactated Ringer's was begun. He is to receive $8,000 \mathrm{~mL}$ of solution in 24 hours. According to the Parkland formula, how much solution should he receive by 11:30 p.m.?

Correct Answer: C

Rationale: The Parkland formula states half the total fluid (4,000 mL) is given in the first 8 hours (by 3:30 p.m.), and the remaining 4,000 mL over the next 16 hours. By 11:30 p.m. (16 hours post-burn), the client should have received 6,000 mL.

Question 4 of 5

The nurse observes a certified nursing assistant (CNA) moving a client up in bed. Which action by the nursing assistant indicates a need for more instruction in how to move a client?

Correct Answer: D

Rationale: Pulling by the shoulders risks injury to the client's skin and joints. Using a pull sheet, getting help, and lowering the bed are correct techniques to ensure safety.

Question 5 of 5

The nurse reviews a prescription to insert an indwelling urinary catheter in a hospitalized client. Which rationale for indwelling urinary catheter insertion is most appropriate?

Correct Answer: A

Rationale: Acute urinary retention (
A) is a medical indication for catheterization. Confusion/incontinence (
B), fall risk (
C), and diuretics (
D) are not sufficient justifications.

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