NCLEX Questions, NCLEX RN Free Practice Questions Questions, NCLEX-RN Questions, Nurselytic

Questions 158

NCLEX-RN

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Question 1 of 5

The nurse who is caring for a client with cancer notes a WBC of 500/mm3 on the laboratory results. Which intervention would be most appropriate to include in the client's plan of care?

Correct Answer: B

Rationale: A WBC of 500/mm3 indicates severe neutropenia, increasing infection risk. Avoiding crowds and sick people (
B) is critical. Hypothermia (
A) is not a primary concern, soft toothbrush (
C) prevents bleeding, and bleeding (
D) is for thrombocytopenia.

Question 2 of 5

A 19-year-old client fell off a ladder approximately 3 ft to the ground. He did not lose consciousness but was taken to the emergency department by a friend to have a scalp laceration sutured. The nurse instructs the client to:

Correct Answer: C

Rationale: Confusion, nausea, or vomiting may indicate increasing intracranial pressure from a possible head injury, requiring immediate evaluation.

Question 3 of 5

A cardinal symptom of the schizophrenic client is hallucinations. A nurse identifies this as a problem in the category of:

Correct Answer: B

Rationale: Impaired communication refers to decreased ability or inability to use or understand language in an interaction. In sensory-perceptual alterations an individual has distorted, impaired, or exaggerated responses to incoming stimuli (i.e., a hallucination, which is a false sensory perception that is not associated with real external stimuli). An altered thought processes problem statement is used when an individual experiences a disruption in cognitive operations and activities (i.e., delusions, loose associations, ideas of reference). In impaired social interaction, the individual participates too little or too much in social interactions.

Question 4 of 5

A 67-year-old man had a physical examination prior to beginning volunteer work at the hospital. A routine chest x-ray demonstrated left ventricular hypertrophy. His blood pressure was 180/110. He is 45 lb overweight. His diet is high in sodium and fat. He has a strong family history of hypertension. The client is placed on antihypertensive medication; a low-sodium, low-fat diet; and an exercise regimen. On his next visit, compliance would best be determined by:

Correct Answer: A

Rationale: A blood pressure within acceptable range best demonstrates compliance, but weight loss cannot be accomplished without adherence to medication, diet, and exercise. Absence of side effects does not indicate compliance with medication. Pill counts can be misleading because the client can alter pill counts prior to visit. Left ventricular hypertrophy is not an accurate measure of compliance because hypertrophy frequently does not decrease even with pharmacological management. Therapeutic blood levels measure the drug level at the time of the test. There is no indication of compliance several days before testing.

Question 5 of 5

The nurse is teaching a client with a history of osteoporosis about dietary modifications. The nurse should tell the client to increase intake of:

Correct Answer: A

Rationale: Calcium-rich foods strengthen bones and help prevent further bone loss in osteoporosis, a critical dietary modification.

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