NCLEX Questions, NCLEX-RN Exam Practice Questions, NCLEX-RN Questions, Nurselytic

Questions 157

NCLEX-RN

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Extract:


Question 1 of 5

Which of the following changes in blood pressure readings should be of greatest concern to the nurse when assessing a prenatal client?

Correct Answer: D

Rationale: (A, B,
C) The individual's systolic and diastolic changes are more significant than the relatively high initial blood pressure readings. The systolic pressure went up 12 mm Hg and the diastolic pressure 18 mm Hg. This is a more significant rise than the increases in A-C choices, and client should receive more frequent evaluations and care.

Question 2 of 5

The nurse is assigning staff to care for a number of clients with emotional disorders. Which facet of care is suitable to the skills of the nursing assistant?

Correct Answer: B

Rationale: Providing routine catheter care is within the scope of a nursing assistant, as it involves basic hygiene tasks, unlike the other options, which require advanced assessment or monitoring.

Question 3 of 5

A client with a C4 spinal cord injury has been placed in traction with cervical tongs. Nursing care should include:

Correct Answer: D

Rationale: Sterile pin care prevents infection at the cervical tong insertion sites, a critical nursing responsibility. Releasing traction, loosening pins, or elevating the bed risks spinal instability.

Question 4 of 5

The physician has ordered Coumadin (sodium warfarin) for a client with a history of clots. The nurse should tell the client to avoid which of the following vegetables?

Correct Answer: B

Rationale: Cauliflower is high in vitamin K, which can counteract the anticoagulant effects of warfarin, so it should be limited.

Question 5 of 5

A client with type 2 diabetes is prescribed metformin (Glucophage). Which statement by the client indicates a need for further teaching?

Correct Answer: C

Rationale: Stopping metformin abruptly (
C) can worsen glycemic control, indicating a need for further teaching. Taking with meals (
A), monitoring sugar (
B), and reporting muscle pain (
D) are correct.

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