NCLEX Questions, NCLEX Practice Test RN Questions, NCLEX-RN Questions, Nurselytic

Questions 158

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Question 1 of 5

The nurse teaches a male client ways to reduce the risks associated with furosemide therapy. Which of the following indicates that he understands this teaching?

Correct Answer: A

Rationale: Rising slowly prevents postural hypotension, a common side effect of furosemide that increases fall risk. The other options are not specific to furosemide therapy risks.

Question 2 of 5

The physician of an alcoholic client places him on a low-protein, high-carbohydrate diet. When choosing his menu, the client's best choice from the items below would be:

Correct Answer: C

Rationale: Serum ammonia levels can be decreased by restricting dietary protein intake. Waffles, honey, and orange juice are high in carbohydrate and low or completely lacking in protein. Butter, a concentrated fat, will provide extra calories.

Question 3 of 5

A 48-year-old client is being seen in her physician's office for complaints of indigestion, heartburn, right upper quadrant pain, and nausea of 4 days' duration, especially after meals. The nurse realizes that these symptoms may be associated with cholecystitis and therefore would check for which specific sign during the abdominal assessment?

Correct Answer: C

Rationale: This sign is a faint blue discoloration around the umbilicus found in clients who have hemorrhagic pancreatitis. This sign indicates areas of inflammation within the peritoneum, such as with appendicitis. It is a deep palpation technique used on a nontender area of the abdomen, and when the palpating hand is removed suddenly, the client experiences a sharp, stabbing pain at an area of peritoneal inflammation. This sign is considered positive with acute cholecystitis when the client is unable to take a deep breath while the right upper quadrant is being deeply palpated. The client will elicit a sudden, sharp gasp, which means the gallbladder is acutely inflamed. This is a sign of acute hemorrhagic pancreatitis and manifests as a green or purple discoloration in the flanks.

Question 4 of 5

Discharge teaching for the client who has a total gastrectomy should include which of the following?

Correct Answer: C

Rationale: There will be no need to increase fluid intake excessively, because dumping syndrome could present a problem. Follow-up visits every 3 weeks are not a standard recommendation. Follow-up visits will be highly individualized. With removal of the stomach, intrinsic factor will no longer be produced. Intrinsic factor is necessary for vitamin B12 absorption. Parenteral injections of B12 will be needed on a monthly basis for the rest of the person's life. Smaller, more frequent meals, rather than large, bulky meals, are recommended to prevent problems with dumping syndrome.

Question 5 of 5

A client has been diagnosed with thrombophlebitis. She asks, 'What is the most likely cause of thrombophlebitis during my pregnancy?' The nurse explains:

Correct Answer: A

Rationale: During pregnancy, the potential for thromboses increases owing to the increased levels of coagulation factors and a decrease in the breakdown of fibrin.

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