NCLEX Questions, NCLEX Trainer Test 3 Questions, NCLEX-PN Questions, Nurselytic

Questions 157

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Question 1 of 5

A psychiatric nurse is assigned to conduct an admission nursing history on a new client.

Correct Answer: C

Rationale: A comprehensive psychiatric nursing history should use a biopsychosocial approach, including physical, psychological, social, and family system assessments, to provide a holistic understanding of the client’s needs. Focusing only on emotional state or mental status is too narrow, and the nurse’s opinion lacks objectivity without assessment data.

Question 2 of 5

A Miller-Abbott tube is ordered for a client. The nurse knows that the main reason this tube is inserted is to

Correct Answer: D

Rationale: Miller-Abbott tube provides for inTest inal decompression; inTest inal tube is often used for treatment of paralytic ileus

Question 3 of 5

A 15-year old is admitted following a motor vehicle accident. Examination reveals that the client has a closed head injury, a linear fracture of the temporal bone, a fracture of the mandible, and multiple abrasions. Upon admission, he is very drowsy. Which of the following orders would not be a part of the patient's care?

Correct Answer: D

Rationale: Demerol is contraindicated in head injuries due to its potential to mask neurological changes and increase intracranial pressure.

Question 4 of 5

The nurse is caring for a client who is receiving IV fluids at 150 mL/hour. Which of the following findings indicates fluid overload?

Correct Answer: C

Rationale: Crackles in the lung bases suggest pulmonary edema from fluid overload. Options A, B, and D are normal findings.

Question 5 of 5

Docusate sodium (Colace) is ordered for an adult who had a myocardial infarction yesterday. The client asks the nurse why docusate sodium is prescribed. The nurse's response should include which information?

Correct Answer: D

Rationale: Docusate sodium is a stool softener, reducing straining during bowel movements, which decreases cardiac strain post-MI.

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