NCLEX RN practice test NGN LATEST VERSION with Rationale

NCLEX RN practice test NGN LATEST VERSION with Rationale During a urinary bladder catheter insertion with a size 16 french catheter on an older adult male client, the nurse feels increased resistance. Which action by the nurse is best? - ANS-STOP THE INSERTION AND INSTRUCT THE CLIENT TO TAKE DEEP BREATHS rationale*** for the safety of the client, the nurse should never force a catheter if there is increased resistance. Instructing the client to take deep breaths will help to relax the urethral muscles and facilitate passage of the catheter. -catheter should not be withdrawn and reinstered, as this increases the rf infection the nurse reviews the record of a client diagnosed with acute kidney injury (AKI). It is most important for the nurseto review which lab value? - ANS-URINE SPECIFIC GRAVITY rationale*** specific gravity can indicate fluid volume excess or deficit and is the most important of the lab values to assess a client is admitted for dehydration. the nurse observed that the client appears restless and reports difficulty breathing. The nurse auscultes the client's lungs and hears bilateral basilar crackles. Which action does the nurse take first? - ANS-ELEVATE THE HEAD OF THE BED AND STOP THE iv INFUSION rationale*** it addresses the clients difficulty breathing and indications of fluid volume overload A client diagnosed with chronic lymphocytic leukemia (CLL) is scheduled for a bone marrow aspiration biospy. The client says "I am frightened I have never had this test before and I dont know what to expect." Which statement will the nurse include when responding to the client's concerns? SATA - ANS-*** rationale- "A tight pressure dressing will be placed over the test site after the procedure" -There is a risk of bleeding so will monitor the test site frequently BM biopsy - ANS-- can be done in pt room or treatment room rationale-pressure dressing applied to reduce rf bleeding -stinging and discomfort furing biopsy is expected -monitor for bleeding -local anesthetic used