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

Questions 157

NCLEX-PN

NCLEX-PN Test Bank

ATI NCLEX-PN Practice Questions Questions

Extract:


Question 1 of 5

The client diagnosed with end-stage congestive heart failure is being cared for by the home health nurse. Which intervention should the nurse teach the caregiver?

Correct Answer: B

Rationale: Weight gain >3 lb/week indicates fluid retention in CHF, requiring HCP notification to adjust therapy.

Question 2 of 5

The unlicensed assistive personnel (UAP) notifies the nurse the client diagnosed with chronic obstructive pulmonary disease is complaining of shortness of breath and would like his oxygen level increased. Which intervention should the nurse implement?

Correct Answer: C

Rationale: A pulse oximeter reading assesses oxygenation status, guiding whether oxygen adjustment is needed.

Question 3 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.

Order the Items

Source Container

Write the client problem of 'altered tissue perfusion.'
Assess the client's level of consciousness and speech.
Request dietary to send a full liquid tray with Thick-It.
Instruct the UAP to elevate the head of the bed 30 degrees.
Note the amount of food consumed on the dinner tray.

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 4 of 5

The female client with a cold is prescribed warfarin (Coumadin), an anticoagulant, for chronic atrial fibrillation. The client calls the clinic and tells the nurse she is bleeding and bruising more than normal. Which information indicates a need for further teaching?

Correct Answer: A

Rationale: Echinacea may interact with warfarin, increasing bleeding risk, indicating a need for teaching about herb-drug interactions. Monthly INR, acetaminophen (safe with warfarin), and label reading are appropriate.

Question 5 of 5

Which intervention should the circulating nurse implement for the preoperative elderly client who is anxious and diaphoretic?

Correct Answer: A

Rationale: Soft, slow music reduces anxiety and promotes relaxation in the OR, safe for an elderly client. Rapid breaths worsen anxiety, talking may not suffice, and opening doors breaks asepsis.

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