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

Questions 164

NCLEX-PN

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Extract:


Question 1 of 5

The nurse auscultates the heart sounds of a 77-year-old client with chronic heart failure. Which heart sound should the nurse document?

Correct Answer: C

Rationale: An S3 heart sound is commonly associated with heart failure due to fluid overload and ventricular dysfunction.

Question 2 of 5

During a situation of pain management, which statement is a priority to consider for the ethical guidelines of the nurse?

Correct Answer: A

Rationale: The client's self-report is the most important consideration. Pain is a complex phenomenon that is perceived differently by each individual. Pain is whatever the client says it is. The other statements are correct but not the most important considerations.

Question 3 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 4 of 5

A behavior modification program is planned for an adolescent who exhibits disruptive behavior. Which action by the nurse is most consistent with a behavior modification program?

Correct Answer: B

Rationale: Positive reinforcement (extra privileges for non-disruptive behavior) aligns with behavior modification, encouraging desired actions. Punishment, reminders, or asking perceptions are less effective.

Question 5 of 5

The nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? Select all that apply.

Correct Answer: A,B,D

Rationale: Suctioning, side-lying position, and assistance protect the client. Restraining or using a tongue blade can cause injury.

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