NCLEX Questions, NCLEX RN Predictor Exam Questions, NCLEX-RN Questions, Nurselytic

Questions 158

NCLEX-RN

NCLEX-RN Test Bank

NCLEX RN Predictor Exam Questions

Extract:


Question 1 of 5

A male client is experiencing auditory hallucinations. His nurse enters the room and he tells her that his mother is talking to him, and he will take his medicine after she leaves. The nurse looks around the room and sees that she and the client are the only ones in the room. The nurse's most therapeutic response will be:

Correct Answer: A

Rationale: This response uses the principle of reality orientation by the nurse telling the client that he or she does not see anything, but it does recognize his feelings.

Question 2 of 5

The mother of a two-year-old with burns over 40% of the body asks the nurse how long it will take for the burns to heal. The nurse’s response is based on the knowledge that second-degree burns require:

Correct Answer: C

Rationale: Second-degree burns, affecting the epidermis and dermis, typically heal in 14–21 days with proper care. Healing time depends on depth and infection control, but 14–21 days is standard.

Question 3 of 5

A client has been hospitalized with a diagnosis of laryngeal cancer. Which factor is most significant in the development of laryngeal cancer?

Correct Answer: D

Rationale: Alcohol and tobacco use are the most significant risk factors for laryngeal cancer due to their carcinogenic effects on the laryngeal mucosa. Family history, fumes, and vocal strain are less impactful.

Question 4 of 5

A female client was employed as a client care technician in a hemodialysis unit. She recently began to experience extreme fatigue, being able to sleep for 16-20 hours at a time. She also noted that her urine was tea colored, which she rationalized was a result of the vitamins she began taking to alleviate fatigue. She was diagnosed with hepatitis B. After a brief hospital stay, she is discharged to her parent's home. Her mother asks the nurse if any precautions are necessary to prevent transmission to the client's family. The nurse explains necessary precautions, which include:

Correct Answer: B

Rationale: Isolation is not necessary, even in the acute phase. Separate bathroom facilities are recommended. If unavailable, daily cleansing with a chloride solution is recommended. Precautions continue to be necessary while the client is in the active phase of hepatitis. Clothes are to be laundered separately in hot water with a chloride solution.

Question 5 of 5

A 68-year-old man was recently diagnosed with endstage renal disease. He has not yet begun dialysis but is experiencing severe anemia with associated symptoms of dyspnea on exertion and chest pain. Which statement best describes the management of anemia in renal failure?

Correct Answer: D

Rationale: Clients in renal failure typically have very low hematocrits, often in the range of 16-22%. Transfusion is avoided unless the client exhibits acute symptoms such as dyspnea, chest pain, tachycardia, and extreme fatigue. When the client is given a transfusion, the bone marrow adjusts by producing less red blood cells. Anemia in renal failure is caused primarily by decreased erythropoietin. Low serum iron and ferritin may aggravate the anemia and require treatment. Decreased secretion of erythropoietin by the kidney is the primary cause of anemia. The bone marrow requires this hormone to mature red blood cells. Treatment is with replacement therapy.

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