NCLEX Questions, ATI NCLEX-RN Practice Questions Questions, NCLEX-RN Questions, Nurselytic

Questions 158

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Question 1 of 5

During an intake assessment, the nurse asks the client if he has an advanced directive. The reason for asking the client this question is:

Correct Answer: B

Rationale: An advanced directive clarifies a client’s wishes for medical care, reducing confusion and conflict among family or healthcare providers, especially in critical situations. It does not address funeral plans, allow staff to make decisions, or permit euthanasia.

Question 2 of 5

Other drugs may be ordered to manage a client's ulcerative colitis. Which of the following medications, if ordered, would the nurse question?

Correct Answer: D

Rationale: 6-Mercaptopurine is used for Crohn's disease, not ulcerative colitis, so the nurse should question its order.

Question 3 of 5

The nurse is caring for a client with a history of a mastectomy. The client complains of arm swelling. The nurse should:

Correct Answer: B

Rationale: Arm swelling post-mastectomy suggests lymphedema, and elevating the arm reduces fluid accumulation. Warm compresses and massage may worsen swelling, and notification is secondary.

Question 4 of 5

A 35-year-old primigravida comes to the clinic for her first prenatal visit. The midwife, on examining the client, suspects that she is approximately 11 weeks pregnant. The pregnancy is positively confirmed by finding:

Correct Answer: B

Rationale: Chadwick's sign is a presumptive sign of pregnancy. The coloration may not subside from past pregnancy or could be caused by other situations that create vasocongestion. FHR (movement) observed DISTINCT on ultrasound is a positive diagnosis of pregnancy. Enlargement of the uterus may be due to fibroids or infection. It is considered a probable sign. Breast tenderness and enlargement is a presumptive sign because it may be due to other conditions, such as premenstrual changes.

Question 5 of 5

The nurse is caring for a client following a laryngectomy. The nurse can best help the client with communication by:

Correct Answer: A

Rationale: A pad and pencil allow immediate, effective communication for a client post-laryngectomy, who cannot speak due to removal of the voice box.

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