NCLEX Questions, NCLEX Practice Test RN Questions, NCLEX-RN Questions, Nurselytic

Questions 158

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Question 1 of 5

A 5-year-old child was recently diagnosed as having acute lymphoid leukemia. She is hospitalized for additional tests and to begin a course of chemotherapy designed to induce a remission. She is scheduled to have a bone marrow aspiration tomorrow. She has had a bone marrow test previously and is apprehensive about having another. Which of the following interventions will be most effective in relieving her anxiety?

Correct Answer: A

Rationale: Providing a detailed explanation of the procedure helps reduce anxiety by preparing the child for what to expect, addressing her previous experience.

Question 2 of 5

In admitting a client to the psychiatric unit, the nurse must explain the rules and regulations of the unit. A client with antisocial personality disorder makes the following remark, 'Forget all those rules. I always get along well with the nurses.' Which nursing response to him would be most effective?

Correct Answer: B

Rationale: This answer is incorrect. A nurse should be an appropriate role model. Threats are not appropriate. No limit setting was stated. This answer is correct. The nurse made a positive statement followed by a simple, clear, concise setting of limits. This answer is incorrect. It appears to have a negative connotation. There was no limit setting. This answer is incorrect. The nurse obviously responded in a negative manner. Learning takes place more readily when one is accepted, not rejected. No limits were set.

Question 3 of 5

The nurse is caring for a client with a history of a pneumothorax who is being prepared for discharge. The nurse should teach the client to:

Correct Answer: A

Rationale: Air travel can cause pressure changes that risk pneumothorax recurrence. Sleeping position, lifting, and fluids are secondary, with lifting typically restricted.

Question 4 of 5

The client is admitted with a diagnosis of postpartum depression. Which vital sign change is most likely to be observed?

Correct Answer: A

Rationale: Postpartum depression is a psychological condition and typically does not cause vital sign changes. Fever tachycardia or hypotension suggest physical conditions like infection or hemorrhage.

Question 5 of 5

A client is taking Rifadin (rifampin) 600 mg PO daily for pulmonary tuberculosis. The nurse should tell the client to:

Correct Answer: B

Rationale: Rifampin causes harmless red-orange discoloration of urine, sweat, and tears, which clients should be informed about to avoid alarm. It can be taken with or without food, timing is not restricted to bedtime, and it is taken daily, not conditionally.

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