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Questions 158

NCLEX-RN

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Extract:


Question 1 of 5

Which task should be delegated to the licensed practical nurse?

Correct Answer: A, B, D, E

Rationale: LPNs can administer subcutaneous heparin (
A), feed via PEG tube (
B), monitor chest tubes (
D), and perform tracheostomy care (E). Removing a PICC line (
C) requires RN-level expertise due to potential complications.

Question 2 of 5

The nurse is caring for a client with a history of a fractured humerus who is in a sling. The client complains of numbness. The nurse should:

Correct Answer: C

Rationale: Numbness in a slung humerus suggests neurovascular compromise, requiring immediate physician notification. Ice, elevation, and massage are insufficient or contraindicated.

Question 3 of 5

Which one of the following statements is correct when measuring the client for crutches?

Correct Answer: B

Rationale: Proper crutch fitting requires a gap of about three inches (or two to three fingerbreadths) between the crutch top and the axilla to prevent nerve damage. The elbow should flex at about 30°, and crutches extend about 6 inches laterally from the foot.

Question 4 of 5

A male client received a heart-lung transplant 1 month ago at a local transplant center. While visiting the nursing center to have his blood pressure taken, he complains of recent weakness and fatigue. He also tells the nurse that he is considering stopping his cyclosporine because it is expensive and is causing his face to become round. He fears he will catch viruses and be more susceptible to infections. The nurse responds to this last statement by explaining that cyclosporine:

Correct Answer: A

Rationale: Cyclosporine is the immunosuppressive drug of choice. It provides immunosuppression but does not lower the white blood cell count; therefore, the client is less susceptible to infection. Cyclosporine is available at discount pharmacies. The cost may be absorbed by health insurance, or Medicare, if the client is eligible. However, this statement does not address the entire problem verbalized by the client. Immunosuppressive agents will be taken for the client's entire life because rejection can occur at any time. These side effects do not necessarily resolve in time; however, the client may adapt.

Question 5 of 5

The nurse is teaching the client with hepatitis B regarding transmission. The nurse should instruct the client to do which of the following?

Question Image

Correct Answer: B, E

Rationale: Hepatitis B is transmitted via blood and bodily fluids. Avoiding sharing toothbrushes (
B) prevents transmission through saliva or blood. Informing the dentist (E) ensures precautions during procedures. Eating fresh produce (
A), cleaning the commode (
C), and boiling water (
D) are unrelated to hepatitis B transmission.

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