NCLEX 3500 Nursing Exam Questions with 100% Verified Correct Answers 2024/2025 The nurse is examining a client with suspected peritonitis. How does the nurse elicit rebound tenderness - Correct Answer Pressing the affected area firmly with one hand, releasing pressure quickly, and noting any tenderness on release The nurse is caring for a client who has suffered a severe stroke. During routine assessment, the nurse notices Cheyne-Stokes respirations. Cheyne-Stokes respirations are: - Correct Answer progressively deeper breaths followed by shallower breaths with apneic periods.The nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3-, 24 mEq/L. What do these values indicate? - Correct Answer Respiratory alkalosis Why shouldn't the nurse palpate both carotid arteries at one time? - Correct Answer It may cause severe bradycardia.The nurse measures a client's apical pulse rate and compares it with the radial pulse rate. The differential between these two pulses is called: - Correct Answer the pulse deficit.A client with fever, weight loss, and watery diarrhea is being admitted to the facility. While assessing the client, a nurse inspects the client's abdomen and notices that it's slightly concave. Additional assessment should proceed in which order? - Correct Answer Auscultation, percussion, and palpation The nurse is monitoring a client for adverse reactions during barbiturate therapy. What is the major disadvantage of barbiturate use? - Correct Answer Potential for drug dependence During assessment, the nurse auscultates for a client's breath sounds. Auscultation produces which type of data? - Correct Answer Objective A child with rheumatic fever must have his heart rate measured while awake and while sleeping.Why are two readings necessary? - Correct Answer To compensate for the effects of activity on the heart rate To evaluate a client's posterior tibial pulse, where should the nurse palpate? - Correct Answer On the inner aspect of the ankle, below the medial malleolus 1 / 2
At 8 a.m., the nurse assesses a client who's scheduled for surgery at 10 a.m. During the assessment, the nurse detects dyspnea, a nonproductive cough, and back pain. What should the nurse do next? - Correct Answer Notify the physician immediately of these findings When a nurse enters the client's room, the client complains that she's spitting up blood when she coughs. The nurse takes a quick health history that includes: - Correct Answer the history of the present problem, allergies, medications, and recent major operations.The nurse is auscultating a client's chest. How can the nurse differentiate a pleural friction rub from other abnormal breath sounds? - Correct Answer A rub occurs during both inspiration and expiration and produces a squeaking or grating sound.When auscultating a client's abdomen, the nurse detects high-pitched gurgles over the lower right quadrant. Based on this finding, the nurse suspects: - Correct Answer nothing abnormal.The nurse prepares to perform an otoscopic examination on an adult. For proper visualization, the nurse should position the client's ear by pulling the: - Correct Answer helix up and back.The nurse is helping to plan a teaching session for a client who will be discharged with a colostomy.When describing a healthy stoma, which statement should the nurse be sure to include? - Correct Answer "At first, the stoma may bleed slightly when touched." The nurse is assessing a client's abdomen. Which finding should the nurse report as abnormal? - Correct Answer Shifting dullness over the abdomen After suctioning a tracheostomy tube, the nurse assesses the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent? - Correct Answer Effective breathing at a rate of 16 breaths/minute through the established airway The nurse is evaluating a client's auditory function. To compare air conduction to bone conduction, the nurse should conduct which test? - Correct Answer Rinne test A mother comes to the clinic with her 5-year-old son who's complaining of a fever and sore throat.The nurse documents the client's tonsils as 3+. This means they're: - Correct Answer touching the uvula.
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