Questions 151

NCLEX-RN

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Question 1 of 5

You are planning discharge education for your client who has a new colostomy. Which complication of a colostomy should you educate this client about?

Correct Answer: A

Rationale: A prolapsed stoma is a potential complication of a colostomy, and clients should be educated to recognize and report it.

Question 2 of 5

You measure your 2 year old client's vital signs as: • Respiratory rate: 32 breaths per minute • Pulse: 110 beats per minute • Blood pressure: 55/82. The mother asks you if these vital signs are normal. You should respond to this mother's question by stating:

Correct Answer: C

Rationale: For a 2-year-old, normal ranges are approximately: respiratory rate 20-30 breaths/min, pulse 80-130 beats/min, blood pressure ~90/55 mmHg. The blood pressure (55/82) is low (systolic is below normal), while the respiratory rate and pulse are within or slightly above normal ranges.

Question 3 of 5

The nurse is caring for a client with a history of hyperthyroidism who is prescribed methimazole (Tapazole). The nurse should monitor the client for which of the following adverse effects?

Correct Answer: A

Rationale: Methimazole can cause agranulocytosis, a serious reduction in white blood cells, requiring monitoring.

Question 4 of 5

Which of the following is considered an internal disaster?

Correct Answer: A

Rationale: An internal disaster is an event within the healthcare facility, such as a tornado directly affecting it, requiring internal emergency protocols.

Question 5 of 5

The nurse is caring for a client with a history of chronic obstructive pulmonary disease who is receiving oxygen therapy. Which of the following flow rates is most appropriate for this client?

Correct Answer: A

Rationale: A flow rate of 1-2 L/min via nasal cannula is appropriate for COPD clients to avoid suppressing their hypoxic respiratory drive.

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