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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 49 )

Updated On: 12-Jan-2026
Page 49 of 345
PDF with 862 Questions

A client who has sustained a basilar skull fracture exhibits blood-tinged drainage from his nose. After establishing a clear airway, administering supplemental O2, and establishing IV access, the next nursing intervention would be to:

  1. Pass a nasogastric tube through the left nostril
  2. Place a 4 X 4 gauze in the nares to impede the flow
  3. Gently suction the nasal drainage to protect the airway
  4. Perform a halo test and glucose level on the drainage

Answer(s): D

Explanation:

(A) Basilar skull fracture may cause dural lacerations, which result in CSF leaking from the ears or nose. Insertion of a tube could lead to CSF going into the brain tissue or sinuses. (B) Tamponading flow could worsen the problem and increase ICP. (C) Suction could increase brain damage and dislocate tissue. (D) Testing the fluid from the nares would determine the presence of CSF. Elevation of the head, notification of the medical staff, and prophylactic antibiotics are appropriate therapy.



A client with emphysema is placed on diuretics. In order to avoid potassium depletion as a side effect of the drug therapy, which of the following foods should be included in his diet?

  1. Celery
  2. Potatoes
  3. Tomatoes
  4. Liver

Answer(s): B

Explanation:

(A) Celery is high in sodium. (B) Potatoes are high in potassium. (C) Tomatoes are high in sodium. (D) Liver is high in iron.



The medication that best penetrates eschar is:

  1. Mafenide acetate (Sulfamylon)
  2. Silver sulfadiazine (Silvadene)
  3. Neomycin sulfate (Neosporin)
  4. Povidone-iodine (Betadine)

Answer(s): A

Explanation:

(A) Mafenide acetate is bacteriostatic against gram-positive and gram-negative organisms and is the agent that best penetrates eschar. (B) Silver sulfadiazine poorly penetrates eschar. (C) Neomycin sulfate does not penetrate eschar. (D) Povidoneiodine does not penetrate eschar.



When inspecting a cardiovascular client, the nurse notes that he needs to sit upright to breathe. This behavior is most indicative of:

  1. Pericarditis
  2. Anxiety
  3. Congestive heart failure
  4. Angina

Answer(s): C

Explanation:

(A) Pericarditis can cause dyspnea but primarily causes chest pain. (B) Anxiety can cause dyspnea resulting in SOB, yet it is not typically influenced by degree of head elevation. (C) The inability to oxygenate well without being upright is most indicative of congestive heart failure, due to alveolar drowning. (D) Angina causes primarily chest pain; any SOB associated with angina is not influenced by body position.



Dietary planning is an essential part of the diabetic client's regimen. The American Diabetes Association recommends which of the following caloric guidelines for daily meal planning?

  1. 50% complex carbohydrate, 20%­25% protein, 20%­25% fat
  2. 45% complex carbohydrate, 25%­30% protein, 30%­35% fat
  3. 70% complex carbohydrate, 20%­30% protein, 10%­20% fat
  4. 60% complex carbohydrate, 12%­15% protein, 20%­25% fat

Answer(s): D

Explanation:

(A) The percentage of carbohydrates is too low to maintain blood sugar levels. The percent range of protein is too high and may cause extra workload on the kidney as it is metabolized. (B) The percentage of carbohydrates is too low to maintain blood sugar levels. The percent range of protein is too high and may cause extra workload on the kidney. (C) The percentage of carbohydrates is too high; the percent range of protein is too high, and of fat, too low. (D) This combination provides enough carbohydrates to maintain blood glucose levels, enough protein to maintain body repair, and enough fat to ensure palatability.



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