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

Questions 158

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Question 1 of 5

When assessing residual volume in tube feeding, the feeding should be delayed if the amount of gastric contents (residual) exceeds:

Correct Answer: D

Rationale: Tube feedings should be withheld and physician notified for residual volumes of 50-100 mL.

Question 2 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 3 of 5

The nurse is preparing to administer a dose of morphine sulfate IV to a client for pain. Which assessment is most important before administration?

Correct Answer: A

Rationale: Morphine, an opioid, can cause respiratory depression. Assessing the respiratory rate is critical before administration to ensure it is above 12 breaths per minute, preventing overdose risk. Other vital signs are monitored but are less critical.

Question 4 of 5

A client admitted for treatment of bacterial pneumonia has an order for intravenous ampicillin. Which specimen should be obtained prior to administering the medication?

Correct Answer: D

Rationale: A sputum culture and sensitivity test is essential before starting antibiotics like ampicillin to identify the causative organism and ensure appropriate treatment for bacterial pneumonia.

Question 5 of 5

The client is prescribed albuterol (Proventil) for asthma. Which side effect should the nurse monitor for?

Correct Answer: B

Rationale: Albuterol, a beta-agonist, stimulates the sympathetic nervous system, causing tremors as a common side effect. Tachycardia (not bradycardia), hypertension, and diarrhea are more likely than hypotension or constipation.

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