NCLEX NCLEX-RN
NCLEX RN Practice Questions Exam Cram
1. Which interventions should the nurse include when creating a care plan for a child with hepatitis? Select one that doesn't apply.
- A. Providing a low-fat, well-balanced diet.
- B. Teaching the child effective hand-washing techniques.
- C. Notifying the primary health care provider (PHCP) if jaundice is present.
- D. Instructing the parents to avoid administering medications unless prescribed.
Correct answer: Instructing the parents to avoid administering medications unless prescribed.
Rationale: The correct answer is instructing the parents to avoid administering medications unless prescribed. This choice is not directly related to the care of a child with hepatitis. It is essential for the nurse to educate the child and family about providing a low-fat, well-balanced diet to support the liver, teaching effective hand-washing techniques to prevent the spread of infection, and notifying the primary health care provider if jaundice is present to monitor the progression of the disease and adjust the treatment plan accordingly. Avoiding unnecessary medications is crucial, but it should be done under healthcare provider guidance, so the statement should be revised to reflect this aspect. Therefore, the other options are appropriate for the care of a child with hepatitis.
2. All of the following are essential components of supervision EXCEPT:
- A. All tasks to be delegated or supervised are within the nurse's scope of practice
- B. The necessary tasks require repeated assessments
- C. The nurse has adequate time to develop staff assignments
- D. Policies have been developed that govern nursing practice
Correct answer: The necessary tasks require repeated assessments
Rationale: Supervision in nursing requires key components to ensure effective management. Tasks to be delegated or supervised must align with the nurse's scope of practice to maintain safety and quality care. Adequate time for staff assignment development is essential for efficient workflow. Policies governing nursing practice provide a framework for safe and standardized care. However, the statement 'The necessary tasks require repeated assessments' is not an essential component of supervision. Tasks should be clear, achievable, and not necessitate repeated assessments, as this would impede delegation and efficient completion. Repeated assessments may indicate unclear task delegation or inadequate initial assessment, which should be avoided in effective supervision.
3. After informing an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly verbalizing a dislike for all healthcare providers and nurses. How should the nurse respond?
- A. Ask the client to remain quiet so the procedure can be performed safely.
- B. Concentrate on completing the insertion as efficiently as possible.
- C. Calmly reassure the client that the discomfort will be temporary.
- D. Tell the client a joke as a means of distraction from the procedure.
Correct answer: Calmly reassure the client that the discomfort will be temporary.
Rationale: The nurse should respond with a calm demeanor to help reduce the client's apprehension. By calmly reassuring the client that the discomfort from the procedure will be temporary, the nurse acknowledges the client's feelings and provides comfort. This response shows empathy and understanding, which can help build trust. Asking the client to remain quiet may escalate the situation and not address the client's underlying concerns. Concentrating solely on completing the insertion efficiently may overlook the client's emotional needs and may increase their anxiety. Telling a joke may not be appropriate in this serious situation and could be perceived as insensitive, failing to address the client's emotional distress effectively.
4. The healthcare professional is taking the health history of a patient being treated for sickle cell disease. After being told the patient has severe generalized pain, the healthcare professional expects to note which assessment finding?
- A. Severe and persistent diarrhea
- B. Intense pain in the toe
- C. Yellow-tinged sclera
- D. Headache
Correct answer: Yellow-tinged sclera
Rationale: In patients with sickle cell disease, severe generalized pain can be associated with vaso-occlusive crises, but yellow-tinged sclera is a common clinical finding related to sickle cell disease. This yellowing of the sclera, known as jaundice, occurs due to the release of bilirubin from damaged or destroyed red blood cells. Severe and persistent diarrhea is not a typical assessment finding in sickle cell disease. Intense pain in the toe may be associated with vaso-occlusive crisis but is not the expected assessment finding in this scenario. Headache is a common symptom in many conditions but is not specifically related to the assessment finding expected in a patient with sickle cell disease presenting with severe generalized pain.
5. An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement?
- A. Assist the client to walk to the bathroom and do not leave the client alone.
- B. Request that the UAP assist the client onto a bedpan.
- C. Ask if the client needs to have a bowel movement or void.
- D. Assess the client's bladder to determine if the client needs to urinate.
Correct answer: Assist the client to walk to the bathroom and do not leave the client alone.
Rationale: Barbiturates cause central nervous system (CNS) depression, increasing the risk of falls. Therefore, the nurse should assist the client to the bathroom to ensure safety. Using a bedpan is not necessary if the client can safely walk to the bathroom. Asking about bowel movements or voiding, as in option C, is irrelevant to the immediate safety concern of assisting the client to the bathroom. Assessing the client's bladder, as in option D, is unnecessary in this situation as there is no indication that the client cannot communicate his or her needs effectively. The priority here is to prevent falls and ensure the client's safety while assisting to the bathroom.
Similar Questions
Access More Features
NCLEX Basic
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access @ $69.99
NCLEX Basic
- 5,000 Questions and answers
- Comprehensive NCLEX Coverage
- 90 days access @ $69.99