Questions 150

NCLEX-RN

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Extract:


Question 1 of 5

You are precepting a new graduate nurse who will be administering an intramuscular injection to an adult client. The new graduate nurse identifies the gluteus maximus muscle by palpating it. What would you do?

Correct Answer: B

Rationale: The vastus lateralis is preferred over the gluteus maximus for IM injections in adults due to lower risk of sciatic nerve injury.

Question 2 of 5

The nurse is evaluating the pin insertion site of a client's skeletal traction. Which of the following indicate a complication?

Correct Answer: C

Rationale: A moving pin indicates instability, a complication risking infection or poor healing. Crusts and serous drainage are normal, and lack of pain is not a complication.

Question 3 of 5

A client with a history of chronic kidney disease is admitted with hyperkalemia. The nurse should prioritize which of the following interventions?

Correct Answer: D

Rationale: Monitoring for dysrhythmias is the priority, as hyperkalemia can cause life-threatening cardiac arrhythmias.

Question 4 of 5

The nurse assesses a client and notes puffy eyelids, swollen ankles, and crackles at both lung bases. The nurse understands that these clinical findings are most specifically associated with fluid excess in which of the following compartments?

Correct Answer: C

Rationale: These symptoms indicate fluid excess in the extracellular compartment, which includes interstitial spaces (edema) and intravascular spaces (contributing to lung crackles).

Question 5 of 5

A client with asthma asks the nurse if she should use her salmeterol (Serevent) inhaler when she exercises and experiences wheezing and shortness of breath. The nurse's best response is which of the following?

Correct Answer: B

Rationale: Salmeterol is a long-acting beta-agonist used for asthma maintenance, not for acute symptoms like wheezing during exercise. A rescue inhaler, such as albuterol, is appropriate for acute symptoms.

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