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NCLEX RN· Physiological Adaptation · NCLEX RN Client Needs Physiological Adaptation

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Showing all 5 practice questions with expert explanatory rationales.

Question 1 of 5

The ED nurse receives a client who is bleeding profusely from a gunshot wound. Which action by the nurse will best help this client avoid complications of extreme blood loss?

A. draw a type and match
B. administer type O blood
C. administer type AB+ blood
D. ask the family to donate blood

Expert Explanatory Rationale

Correct Answer: administer type O blood

Question 2 of 5

Which assessment finding in a client with chronic kidney disease indicates late-stage symptoms?

A. shortness of breath
B. oliguria
C. tea-colored urine
D. edema in lower extremities

Expert Explanatory Rationale

Correct Answer: oliguria

Question 3 of 5

The nurse is caring for a client who is HIV positive and gave birth to a full-term infant. The nurse is teaching the client about infections in HIV-positive infants. Which infection does the nurse understand is the most common opportunistic infection in children and infants with HIV?

A. hepatitis C
B. strep throat
C. cytomegalovirus infection
D. Pneumocystis jiroveci pneumonia

Expert Explanatory Rationale

Correct Answer: Pneumocystis jiroveci pneumonia

Question 4 of 5

The nurse is caring for a client with a sacral wound. The wound is full thickness, measures 4 cm X 6 cm with irregular borders, and is covered by a layer of black collagen. Which is this wound stage?

A. Stage I
B. Stage II
C. Stage III
D. unstageable

Expert Explanatory Rationale

Correct Answer: unstageable

Question 5 of 5

The nurse is preparing to administer cefazolin to a client who is allergic to penicillin. The client states that penicillin causes him to itch and be slightly short of breath. Which response by the nurse is correct?

A. administer the cefazolin as ordered
B. call the pharmacy to substitute another medication
C. hold the medication and notify the health care provider
D. give the client diphenhydramine and then administer the cefazolin

Expert Explanatory Rationale

Correct Answer: hold the medication and notify the health care provider

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