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

Questions 164

NCLEX-PN

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Question 1 of 5

The home health nurse is contributing to the plan of care for a 1-year-old client recently diagnosed with failure to thrive. Which of the following interventions should the nurse recommend including in the client's plan of care? Select all that apply.

Correct Answer: A,B,C,D

Rationale: Assessing parenting, observing feedings, monitoring growth, and reviewing intake identify causes of failure to thrive. Nasogastric tubes are not initially indicated.

Question 2 of 5

The nurse is talking with a client whose spouse recently attempted suicide. The client states, 'If I had not intervened, my spouse would have died. I cannot believe this is happening.' Which of the following responses would be most appropriate for the nurse to make?

Correct Answer: B

Rationale: Acknowledging the client's feelings and encouraging expression provides emotional support.

Question 3 of 5

A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the provider ordering

Correct Answer: B

Rationale: vena caval interruption. Clients with contraindications to Heparin, recurrent PE or those with complications related to the medical therapy may require vena caval interruption by the placement of a filter device in the inferior vena cava. A filter can be placed transvenously to trap clots before they travel to the pulmonary circulation.

Question 4 of 5

A client is on a low-residue diet. All of the following are on the client's tray. Which should be removed?

Correct Answer: C

Rationale: Strawberry jam contains seeds, which increase intestinal residue, contraindicated in a low-residue diet. Roast beef, mashed potatoes, and white bread are low-fiber and appropriate.

Question 5 of 5

The nurse is reinforcing instructions to a client on collection of a sputum specimen for culture and sensitivity. Which of the following client statements indicate that teaching has been effective? Select all that apply.

Correct Answer: A,B,C,E

Rationale: Rinsing the mouth, avoiding contamination, deep coughing, and sitting upright ensure a quality specimen. Morning collection is preferred for higher yield.

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