NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
A client with a history of cardiac problems is having severe chest pain. What should be nurse's first response?
Correct Answer: C
Rationale: Assessing the client's chest pain is the first step to determine its nature and severity, guiding further actions like notifying the physician or administering oxygen or analgesics.
Question 2 of 5
A client is admitted with severe abdominal pains and the diagnosis of acute pancreatitis. The nurse should develop a plan of care during the acute phase of pancreatitis that will involve interventions targeting which of the following problems?
Correct Answer: C
Rationale: Severe pain is a primary concern in acute pancreatitis, requiring targeted interventions like analgesics.
Question 3 of 5
The nurse is caring for a neonate with jaundice receiving phototherapy. Which action is most important?
Correct Answer: A
Rationale: Covering the neonate's eyes protects them from retinal damage due to phototherapy light exposure.
Question 4 of 5
While assessing a term neonate on a home visit to a primiparous client 2 weeks after a vaginal delivery, the nurse observes that the neonate is slightly jaundiced and the stool is a pale, light color. The nurse notifies the physician because these findings indicate which of the following?
Correct Answer: A
Rationale: Pale stools and jaundice in a neonate suggest biliary atresia, a condition requiring urgent evaluation.
Question 5 of 5
You are caring for a client at the end of life. The client tells you that they are grateful for having considered and decided upon some end of life decisions and the appointments of those who they wish to make decisions for them when they are no longer able to do so. During this discussion with the client and the client's wife, the client states that 'my wife and I are legally married so I am so glad that she can automatically make all healthcare decisions on my behalf without a legal durable power of attorney when I am no longer able to do so myself' and the wife responds to this statement with, 'that is not completely true. I can only make decisions for you and on your behalf when these decisions are not already documented on your advance directive.' How should you, as the nurse, respond to and address this conversation between the husband and wife and the end of life?
Correct Answer: C
Rationale: The client's statement reflects a misunderstanding that a spouse automatically assumes the role of durable power of attorney for healthcare decisions without a legal designation. The wife's response is correct in that an advance directive takes precedence, and a durable power of attorney is only effective for decisions not covered by the advance directive. The nurse should recognize the client's knowledge deficit and plan education to clarify the roles of advance directives and durable power of attorney, as stated in option C.