Questions 149

NCLEX-RN

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Question 1 of 5

The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching?

Correct Answer: A

Rationale: Limiting fluid intake to 500 mL per day is incorrect, as adequate hydration is essential in polycythemia vera to reduce blood viscosity and prevent thrombosis.

Question 2 of 5

A nurse is working with an immobile client and doing passive range-of-motion (ROM) exercises on his legs. The client states the exercise is too painful and does not want to continue. The nurse should

Correct Answer: D

Rationale: Pain during ROM exercises may indicate injury. Stopping the exercise prevents harm, with further assessment or pain management to follow.

Question 3 of 5

A child with a known peanut allergy is eating lunch at summer camp and develops an anaphylactic reaction from accidentally ingesting peanut butter-flavored cookies. The nurse's first intervention should be to

Correct Answer: C

Rationale: In an anaphylactic reaction, the priority is to stop further allergen exposure. Verifying the child has stopped eating and has no cookies in their mouth prevents additional allergen ingestion, which is critical before administering epinephrine or other interventions.

Question 4 of 5

The doctor has ordered Ampicillin 100 mg every 6 hours IV push for an infant weighing 7 kg. The suggested dose for infants is 25-50 mg/kg/day in equally divided doses. The nurse should:

Correct Answer: D

Rationale: The ordered dose (400 mg/day) exceeds the safe range (175-350 mg/day for a 7 kg infant), requiring the nurse to verify the order with the doctor.

Question 5 of 5

When caring for a ventilator-dependent client who is receiving tube feedings, the nurse can help prevent aspiration of gastric secretions by:

Correct Answer: B

Rationale: Elevating the head of the bed 30-45° reduces the risk of aspiration in ventilator-dependent clients.

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