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

Questions 158

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Question 1 of 5

To ensure proper client education, the nurse should teach the client taking SL nitroglycerin to expect which of the following responses with administration?

Correct Answer: A

Rationale: Stinging or burning when nitroglycerin is placed under the tongue is to be expected. This effect indicates that the medication is potent and effective for use. Failure to have this response means that the client needs to get a new bottle of nitroglycerin. (B, C,
D) The other responses are not expected in this situation and are not even side effects.

Question 2 of 5

A client is resting comfortably after delivering her first child. When assessing her pulse rate, the nurse would recognize the following finding to be typical:

Correct Answer: D

Rationale: Puerperal bradycardia with rates of 50-70 bpm commonly occurs during the first 6-10 days of the postpartal period. It may be related to decreased cardiac strain, decreased blood volume, contraction of the uterus, and increased stroke volume.

Question 3 of 5

At 16 weeks' gestation, a pregnant client is admitted to the maternity unit to have a McDonald procedure (cerclage) done. She tells the RN who is admitting her to the unit that her physician had explained what this procedure was, but that she did not understand. The RN explains to the client that the purpose for this procedure is to:

Correct Answer: A

Rationale: The treatment most commonly uses the Shirodkar-Barter procedure (McDonald procedure) or cerclage to enforce the weakened cervix by encircling it with a suture at the level of the internal os. There is no known procedure that is used to repair the amniotic sac. Cephalopelvic disproportion is evaluated later in pregnancy. It is not related to this procedure. No procedure is done to dilate the cervix at 16 weeks' gestation unless the pregnancy is to be terminated.

Question 4 of 5

A client with a history of heart failure is admitted with complaints of dyspnea. The nurse should give priority to:

Correct Answer: A

Rationale: Diuretics reduce fluid overload in heart failure, relieving dyspnea and improving oxygenation.

Question 5 of 5

A 49-year-old obese woman has been admitted to the general surgery unit with choledocholithiasis. As the nurse is admitting her to the unit, she states, 'The doctor said I have stones that need to be removed; where are they?' The nurse knows that the best explanation for this is to tell her that:

Correct Answer: C

Rationale: Cholelithiasis is the correct term used to describe the presence of stones in the gallbladder. Nephrolithiasis, or renal calculi, is the correct term used to describe the presence of stones in the kidney. Choledocholithiasis is the correct term used to describe the presence of stones in the common bile duct. Cholecystitis is the correct term used to describe inflammation of the gallbladder and can be associated with cystic duct obstructions from impacted stones.

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