the home health nurse has made a visit to an 85 year old female clients home who has recently had surgery to replace her left knee the client has been
Logo

Nursing Elites

NCLEX-PN

NCLEX PN Practice Questions Quizlet

1. The home health nurse has made a visit to an 85-year-old female client's home who has recently had surgery to replace her left knee. The client has been discharged from a rehab facility and has been able to walk on her own. The nurse assesses the need for teaching related to fall prevention. What should the nurse include in this teaching plan?

Correct answer: A

Rationale: The correct answer is to instruct the client to remove all scatter rugs from the floor and minimize clutter. Rugs and clutter are common causes of falls in the home, especially for the elderly or those with gait issues. Removing them can significantly reduce the risk of falls. While having a raised toilet seat and grab bars in the bathroom is important for safety, it is not the priority in this scenario. The client should not limit her movement within the home unless specifically advised by the physician, as maintaining mobility is essential for recovery. Lastly, the client should avoid wearing robes and socks while walking in the house to prevent tripping, slipping, or falling on slippery floors.

2. The nurse is caring for a 4-year-old client. What is the most appropriate pain scale for the nurse to use during the assessment?

Correct answer: D

Rationale: The correct answer is the Wong-Baker Pain Scale. This scale is specifically designed for pediatric clients, including children as young as 3 years old, making it the most appropriate choice for a 4-year-old. It utilizes a simple visual scale with facial expressions that children can easily understand and use to express their pain levels. The FLACC and CRIES Pain Scales are also used for pediatric clients but are more focused on non-verbal cues and specific populations like infants or critically ill children. The McGill Pain Scale, on the other hand, is more complex and uses descriptive words, making it more suitable for adult clients who can better articulate their pain experiences.

3. While reviewing a client's health care record, a nurse notes documentation of the presence of borborygmus on abdominal assessment. Which finding does the nurse expect to note when auscultating the client's bowel sounds?

Correct answer: C

Rationale: Borborygmus, a type of hyperactive bowel sound, is fairly common. It indicates hyperperistalsis, and the client may describe it as a growling stomach. Hyperactive bowel sounds are loud, high-pitched, and rushing sounds. Hypoactive bowel sounds are low-pitched and may occur post-surgery or with peritoneal inflammation. Low-pitched bowel sounds are not typically associated with borborygmus. An absence of bowel sounds indicates a potentially serious issue like an ileus, where bowel motility is decreased or absent.

4. A mother has come to the pediatric clinic concerned about the recent outbreak of West Nile Virus. The ages of her children are 5, 7, and 10. The mother has asked the nurse what she can do to prevent her children from contracting this illness. Which piece of information is best to provide the mother with?

Correct answer: D

Rationale: The best advice to provide to the mother is 'All of the above.' It is recommended that the children wear insect repellent containing DEET and long-sleeved shirts and long pants when they are outside. This helps in preventing mosquito bites, which can transmit the West Nile Virus. Additionally, removing standing water from areas where the children play can help decrease the number of breeding mosquitoes, reducing the risk of contracting the virus. These methods work in combination to provide effective prevention against the West Nile Virus, making 'All of the above' the correct choice. Choices A, B, and C individually address important prevention measures, but a combination of all three strategies is the most comprehensive approach to protect the children from contracting the illness.

5. The LPN is preparing a client for discharge, and the discharge medications include phenobarbital. Which of these client statements would indicate a need for reinforced teaching about this medication?

Correct answer: C

Rationale: The correct answer is, "I can't wait to get back to my nightly glass of wine,"? as phenobarbital should not be taken with alcohol as it is a barbiturate. Alcohol may increase the sedative effect, posing risks to the patient's safety. Choice A, "I will need to avoid eating excessive leafy greens,"? is unrelated to phenobarbital and not a cause for reinforced teaching. Choice B, "It's best to take this medication with food,"? is a general instruction and not specific to phenobarbital. Choice D, "I should try to take this medication at the same time every day,"? is a common recommendation for medication adherence but does not highlight a specific concern related to phenobarbital.

Similar Questions

A nurse is preparing to test the function of cranial nerve XI. Which action does the nurse take to test this nerve?
A nurse assisting with data collection is preparing to assess the optic nerve. The nurse performs this examination by using which technique?
An LPN is tasked with checking the narcotic count on a medical-surgical unit. Which statement by the LPN requires further investigation?
Which of the following is most likely to impact the body image of an infant newly diagnosed with Hemophilia?
To improve overall health, the nurse should place the highest priority on assisting a client to make lifestyle changes for which of the following habits?

Access More Features

NCLEX PN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX PN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses