which statement made by a patient during an initial assessment interview should serve as the priority focus for the plan of care
Logo

Nursing Elites

NCLEX-RN

NCLEX RN Actual Exam Test Bank

1. During an initial assessment interview, which statement made by a patient should serve as the priority focus for the plan of care?

Correct answer: D

Rationale: The statement about hearing evil voices indicates that the patient is experiencing auditory hallucinations, which is a significant symptom that requires immediate attention and intervention. This symptom can be associated with serious mental health conditions like psychosis. Choices A, B, and C are more general statements that do not provide specific information about the patient's mental health status or symptoms, making them less urgent and not as critical for the plan of care compared to the presence of auditory hallucinations.

2. When preparing a patient on complete bed rest to eat, at what degree angle or more should you put the head of the bed up?

Correct answer: D

Rationale: The correct answer is D: 30. When a patient is on complete bed rest, it is essential to elevate the head of the bed at a 30-degree angle or more before meals. This position helps prevent choking and aspiration of food during eating by promoting proper swallowing and digestion. Choices A, B, and C are incorrect because they do not provide the optimal elevation needed to support safe and effective feeding for a patient on complete bed rest.

3. Who is most likely to arrange the discharge of a patient to their own home, a nursing home, or an assisted living facility?

Correct answer: C

Rationale: Social workers play a crucial role in arranging patient discharges to suitable facilities. They collaborate with healthcare professionals to ensure that patients are transitioned to the most appropriate setting post-hospitalization. Social workers focus on the holistic needs of patients, including their social and emotional well-being, to facilitate a smooth continuum of care. Choices A, B, and D do not typically have the primary responsibility for arranging patient discharges to various facilities.

4. A client has just started a transfusion of packed red blood cells that a physician ordered. Which of the following signs may indicate a transfusion reaction?

Correct answer: A

Rationale: The correct answer is when the client suddenly complains of back pain and has chills. Signs of a transfusion reaction include back pain, chills, dizziness, increased temperature, and blood in the urine. These signs indicate a possible adverse reaction to the blood transfusion. Dependent edema in the extremities is not typically associated with a transfusion reaction. A seizure is not a common sign of a transfusion reaction unless it is due to severe complications. A decrease in heart rate to 60 bpm is not a typical sign of a transfusion reaction, but rather bradycardia may indicate other underlying conditions or medications.

5. What technique would the nurse use to accurately assess a rectal temperature in an adult?

Correct answer: A

Rationale: To accurately assess a rectal temperature in an adult, a nurse should use a lubricated rectal thermometer with a short, blunt tip. The thermometer is inserted only 2 to 3 cm (1 inch) into the rectum and left in place for 2 minutes. Choice B is incorrect as inserting the thermometer 2 to 3 inches would be too deep and inaccurate. Choice C is incorrect as leaving the thermometer in place for up to 8 minutes is unnecessary and can cause discomfort. Choice D is incorrect as smoking a cigarette does not impact rectal temperatures.

Similar Questions

You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to an LPN/LVN?
During a client interview, which of the following leading questions should the nurse avoid asking?
An 86-year-old client with decreased visual acuity who uses a cane for mobility requires fall prevention education. What should the nurse teach this client to reduce the risk of falling at home?
Which of the following is classified as a prerenal condition that affects urinary elimination?
A client who complains of nausea and seems anxious is admitted to the nursing unit. The nurse should take which of the following actions regarding completion of the admission interview?

Access More Features

NCLEX RN Basic
$69.99/ 30 days

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

NCLEX RN Premium
$149.99/ 90 days

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

Other Courses