Questions 150

NCLEX-RN

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Question 1 of 5

Which sound should you expect to hear when you percuss the liver during a complete physical assessment?

Correct Answer: D

Rationale: The liver, a solid organ, produces a dull sound when percussed, as opposed to the tympanic sound of air-filled structures or the resonant sound of lung tissue.

Question 2 of 5

A child with meningococcal meningitis is being admitted to the pediatric unit. In preparation for the child's arrival, the nurse should first?

Correct Answer: A

Rationale: Meningococcal meningitis is transmitted via droplets, so instituting precautions is the priority to prevent spread.

Question 3 of 5

The nurse makes a home visit to a primiparous client and her neonate at 1 week after a vaginal delivery. Which of the following findings should be reported to the physician?

Correct Answer: D

Rationale: Neonatal central cyanosis indicates possible respiratory or cardiac issues and requires immediate reporting. The other findings are normal at 1 week postpartum.

Question 4 of 5

A client with a history of type 2 diabetes mellitus is prescribed metformin (Glucophage). The nurse should instruct the client to report which of the following side effects immediately?

Correct Answer: C

Rationale: Lactic acidosis is a rare but serious side effect of metformin, requiring immediate reporting of symptoms like muscle pain or weakness.

Question 5 of 5

A client with a history of seizures is prescribed phenytoin (Dilantin). The nurse should instruct the client to report which of the following side effects immediately?

Correct Answer: C

Rationale: A rash may indicate a serious hypersensitivity reaction to phenytoin, such as Stevens-Johnson syndrome, requiring immediate reporting.

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