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Questions 227

NCLEX-PN

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Extract:

A client's monitor shows a PQRST wave for each beat and indicates a rate of 120. The rhythm is regular.


Question 1 of 5

The nurse should note that the client is experiencing:

Correct Answer: B

Rationale: A regular rhythm with a rate of 120 and normal PQRST waves indicates sinus tachycardia.

Extract:


Question 2 of 5

The nurse is caring for a client who underwent a lumbar laminectomy 24 hours ago. Which of the following interventions is MOST important?

Correct Answer: D

Rationale: Urinary retention is a common complication post-laminectomy due to spinal anesthesia or nerve irritation, requiring close monitoring to prevent bladder distension. Ambulation (
A) and analgesics (
C) are important, and flat positioning (
B) is recommended but secondary to bladder assessment.

Question 3 of 5

A woman had a hysterectomy this morning. She asks the nurse why she has to wear 'these uncomfortable stockings on my legs.' How should the nurse reply?

Correct Answer: D

Rationale: Compression stockings prevent deep vein thrombosis by promoting venous return, critical post-surgery.

Extract:

If Larissa, an IDDM, is in acute ketoacidosis


Question 4 of 5

The nurse would expect to see which of the following group of symptoms?

Correct Answer: A

Rationale: Ketoacidosis presents with vomiting, thirst, diuresis, and risk of coma due to metabolic acidosis.

Extract:


Question 5 of 5

A patient with cirrhosis is experiencing ascites. Which of the following interventions should the nurse implement?

Correct Answer: B

Rationale: Diuretics reduce fluid overload in ascites, as prescribed. High-sodium diets worsen fluid retention, fluid restriction is typically 1–1.5 liters, and supine positioning may impair breathing.

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