NCLEX Questions, ATI NCLEX-RN Practice Questions Questions, NCLEX-RN Questions, Nurselytic

Questions 158

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Question 1 of 5

To prevent deformities of the knee joints in a client with an exacerbation of rheumatoid arthritis, the nurse should:

Correct Answer: C

Rationale: Encouraging joint motion within pain limits prevents stiffness and deformities in rheumatoid arthritis. Bed rest, discouraging motion, or prolonged immobilization can worsen contractures.

Question 2 of 5

The client is diagnosed with Bell’s palsy. Which intervention should the nurse implement to protect the client’s affected eye?

Correct Answer: A

Rationale: Bell’s palsy causes facial paralysis, impairing eye closure and risking corneal damage. An eye patch at night protects the eye from drying and injury. Corticosteroids reduce inflammation, blinking is encouraged, and antibiotics are not indicated.

Question 3 of 5

The nurse is teaching a client with a history of heart failure about medication adherence. The nurse should tell the client to:

Correct Answer: A

Rationale: Diuretics reduce fluid overload in heart failure, so adherence to prescribed doses is critical to manage symptoms.

Question 4 of 5

A client is receiving IV morphine 2 days after colorectal surgery. Which of the following observations indicate that he may be becoming drug dependent?

Correct Answer: D

Rationale: Frequent requests for pain medication do not necessarily indicate drug dependence after complex surgeries such as colorectal surgery. Sleeping after receiving IV morphine is not an unexpected effect because the pain is relieved. A person may be in pain even with normal vital signs. A subtle sign of drug dependency is the tendency for the person to appear more euphoric than relieved of pain.

Question 5 of 5

A 6-month-old infant who was diagnosed at 4 weeks of age with a ventricular septal defect, was admitted today with a diagnosis of failure to thrive. His mother stated that he had not been eating well for the past month. A cardiac catheterization reveals congestive heart failure. All of the following nursing diagnoses are appropriate. Which nursing diagnosis should have priority?

Correct Answer: D

Rationale: Altered nutrition occurs owing to the fatigue from decreased cardiac output associated with congestive heart failure. The decreased intake occurs due to fatigue from the altered cardiac output. Fatigue occurs due to the decreased cardiac output. The ineffective action of the myocardium leads to inadequate O2 to the tissues, which produces activity intolerance, altered nutrition, and altered growth and development.

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