A client returned to the unit following a pneumonectomy. As the nurse

Free NCLEX RN Exam

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Question 1 of 5.

A client returned to the unit following a pneumonectomy. As the nurse is assessing her incision, she notices fresh blood on the dressing. The nurse should first:

A. Reinforce the dressing.

B. Continue to monitor the dressing.

C. Notify the physician.

D. Note the time and amount of blood.

Explanation: The physician should be notified immediately, because if the bleeding persists, the client may have to be taken back to surgery. Blood on the dressing is unusual and requires prompt action to assess and manage potential complications.

Question 2 of 5.

A client hospitalized with cirrhosis has developed abdominal ascites. The nurse should provide the client with snacks that provide additional:

A. Sodium

B. Potassium

C. Protein

D. Fat

Explanation: Ascites in cirrhosis is linked to hypoalbuminemia; increasing protein intake helps restore albumin levels, reducing fluid accumulation.

Question 3 of 5.

During a unit card game, a client with acute mania begins to sing loudly as she starts to undress. The nurse should:

A. Ignore the client's behavior.

B. Exchange the cards for a checker board.

C. Send the other clients to their rooms.

D. Cover the client and walk her to her room.

Explanation: Covering the client and escorting her to a private area maintains dignity and safety, de-escalating the situation caused by manic behavior.

Question 4 of 5.

A client with a history of phenylketonuria is seen at the local family planning clinic. After completing the client's intake history, the nurse provides literature for a healthy pregnancy. Which statement indicates that the client needs further teaching?

A. I can help control my weight by switching from sugar to Nutrasweet.

B. I need to resume my old diet before becoming pregnant.

C. I need to eliminate most sources of phenylalanine from my diet.

D. Fresh fruits and raw vegetables will make excellent between-meal snacks.

Explanation: Nutrasweet (aspartame) contains phenylalanine, which is harmful in phenylketonuria, so this statement indicates a need for further teaching.

Question 5 of 5.

A client has a tentative diagnosis of myasthenia gravis. The nurse recognizes that myasthenia gravis involves:

A. Loss of the myelin sheath in portions of the brain and spinal cord

B. An interruption in the transmission of impulses from nerve endings to muscles

C. Progressive weakness and loss of sensation that begins in the lower extremities

D. Loss of coordination and stiff 'cogwheel' rigidity

Explanation: Myasthenia gravis is caused by autoantibodies blocking acetylcholine receptors, interrupting nerve impulse transmission to muscles, leading to weakness.

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