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

Questions 148

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Question 1 of 5

Which clinical manifestation during the actual bone marrow transplantation alerts you to the possibility of an adverse reaction?

Correct Answer: D

Rationale: Shortness of breath during bone marrow transplantation may indicate an anaphylactic or transfusion reaction, requiring immediate intervention.

Question 2 of 5

The nurse is caring for the client following a laryngectomy when suddenly the client becomes nonresponsive and pale, with a BP of 90/40. The initial nurse's action should be to:

Correct Answer: B

Rationale: Hypotension and unresponsiveness suggest hypovolemia or shock, so increasing the normal saline infusion is the initial action to restore volume.

Question 3 of 5

A 4-year-old girl has been transferred to a step-down recovery room after a tonsillectomy yesterday. The nurse should place the child in what position while she sleeps?

Correct Answer: D

Rationale: Side-lying position post-tonsillectomy promotes drainage of secretions, reducing airway obstruction risk.

Question 4 of 5

A 5-year-old client with hyperthyroidism is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?

Correct Answer: C

Rationale: Exophthalmos (bulging eyes) is a common sign of hyperthyroidism due to thyroid hormone effects on orbital tissues.

Question 5 of 5

A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client's cervix is 5cm dilated with 75% effacement. Based on the nurse's assessment the client is in which phase of labor?

Correct Answer: A

Rationale: A cervix dilated to 5 cm with 75% effacement indicates the active phase of labor.

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