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Questions 160

NCLEX-PN

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Question 1 of 5

Which assessment finding in a client with heart failure indicates fluid overload? Select all that apply.

Correct Answer: A,B,C,E

Rationale: Weight gain, crackles, jugular vein distention, and peripheral edema are signs of fluid overload in heart failure.

Question 2 of 5

A client with type 2 diabetes mellitus reports feeling shaky and sweaty. The nurse checks the blood glucose level, which is 55 mg/dL. What is the nurse's priority action?

Correct Answer: B

Rationale: A blood glucose of 55 mg/dL indicates hypoglycemia; 15 g of a fast-acting carbohydrate (e.g., juice) is the priority to raise glucose levels.

Question 3 of 5

After a 6-year-old child undergoes a tonsillectomy, the nurse instructs the parents to avoid giving the child aspirin or aspirin products. What is the best explanation for the nurse's instruction?

Correct Answer: B

Rationale: Aspirin is linked to Reye's syndrome in children, a rare but serious condition, especially post-viral infections.

Question 4 of 5

A client with a history of chronic lymphocytic leukemia is at risk for infection. Which nursing intervention is most appropriate?

Correct Answer: A

Rationale: Frequent handwashing reduces infection risk in immunocompromised clients.

Question 5 of 5

The otherwise healthy client who is menopausal tells the nurse that she has been experiencing vaginal itching and burning and increased vaginal infections over the last 2 years. Which statement is the nurse's best response?

Correct Answer: D

Rationale: A. Vaginal infections do not predispose a female to vulvar cancer. B. Although vaginal itching may be related to a contact allergy, it is not the best response. C. Acidic secretions would have a low pH value; the pH increases during menopause. D. Decreased estrogen in menopausal women causes thinning of the vaginal mucosa and an increase in pH of vaginal secretions. As a result, the vagina is easily traumatized and more susceptible to infection.

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