NCLEX Questions, ATI NCLEX-PN Practice Questions Questions, NCLEX-PN Questions, Nurselytic

Questions 157

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ATI NCLEX-PN Practice Questions Questions

Extract:


Question 1 of 5

According to the nursing process, which interventions should the nurse implement when caring for a client diagnosed with a right-sided cerebrovascular accident (stroke) and who has difficulty swallowing? List the interventions in order of the nursing process.

Correct Answer: B,A,C,D,E

Rationale: 1) Assess LOC/speech (assessment); 2) Write problem (diagnosis); 3) Request diet (planning); 4) Instruct HOB elevation (implementation); 5) Note food intake (evaluation).

Question 2 of 5

Which comment by the client diagnosed with rule-out Guillain-Barré (GB) syndrome is most significant when completing the admission interview?

Correct Answer: A

Rationale: Recent gastroenteritis (e.g., Campylobacter) is a known trigger for Guillain-Barré, making it significant.

Question 3 of 5

The client diagnosed with cancer of the larynx has had a partial laryngectomy. Which client problem has the highest priority?

Correct Answer: C

Rationale: Risk for aspiration is the priority post-laryngectomy due to airway alteration, a life-threatening concern.

Question 4 of 5

The client has a fractured right tibia. Which assessment data warrant immediate intervention?

Correct Answer: C

Rationale: A cold foot suggests vascular compromise (e.g., compartment syndrome), requiring immediate intervention to prevent tissue damage.

Question 5 of 5

The client is admitted into the medical unit diagnosed with heart failure and is prescribed the thyroid hormone levothyroxine (Synthroid) orally. Which intervention should the nurse implement?

Correct Answer: A

Rationale: Synthroid is not indicated for heart failure and may worsen cardiac strain; clarifying the order ensures safety.

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