NCLEX Questions, NCLEX RN Practice Questions Quizlet Questions, NCLEX-RN Questions, Nurselytic

Questions 149

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Extract:


Question 1 of 5

A psychiatric nurse is assigned to conduct an admission nursing history on a new client. The admission should include which of the following?

Correct Answer: C

Rationale: complete nursing history includes biopsychosocial data; client’s psychosocial and physical status are evaluated along with an assessment of the client’s family system and social support network; evaluation of the client’s cognitive ability is important during the physiological status assessment

Question 2 of 5

A client who delivered this morning tells the nurse that she plans to breastfeed her baby. The nurse is aware that successful breastfeeding is most dependent on the:

Correct Answer: D

Rationale: The mother's desire to breastfeed is the primary factor influencing breastfeeding success.

Question 3 of 5

A school nurse is suspicious that a child is being physically abused at home. The nurse's responsibility is to

Correct Answer: D

Rationale: Nurses are mandated reporters and must report suspected child abuse to local authorities for investigation, prioritizing child safety.

Question 4 of 5

The client has an order for heparin to prevent post-surgical thrombi. Immediately following a heparin injection, the nurse should:

Correct Answer: D

Rationale: Checking the site for bleeding ensures early detection of hematoma or excessive bleeding post-heparin injection.

Question 5 of 5

A client arrives in the emergency room after a motor vehicle accident. Witnesses tell the nurse that they observed the client's head hit the side of the car door. Nursing assessment findings include BP 70/34, heart rate 130, and respirations 22. Which is the client's most appropriate priority nursing diagnosis?

Correct Answer: B

Rationale: Hypotension (BP 70/34) and tachycardia (HR 130) indicate hypovolemic shock, likely from blood loss. Fluid volume deficit is the priority diagnosis to address life-threatening hypovolemia.

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