NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
The nurse is preparing to do tracheostomy care on a client. Which tracheostomy care items should the nurse obtain to perform this procedure?
Correct Answer: D
Rationale: Equipment needed to perform tracheostomy care includes a tracheostomy care kit, sterile water and saline solutions for cleansing and rinsing, and a suction kit for client suctioning. As part of tracheostomy care, the client's airway should be suctioned before cleansing the tracheostomy. New sterile solutions are obtained once per 24 hours, which is often done at the beginning of the workday. A tracheostomy care kit contains the needed supplies for cleaning the tracheostomy and for changing the dressing and holder (trach ties).
Question 2 of 5
A client with chronic undifferentiated schizophrenia is having an acute exacerbation of symptoms. The client states, 'Black cats and black hats. Where does the time go?' Which of the following would be most important for the nurse to say?
Correct Answer: C
Rationale: Clarifying the client's statement helps assess their thought process and engage therapeutically.
Question 3 of 5
Based on the fact that you family unit client is experiencing a situational crisis that has led to dysfunctional communication within the family unit, you have recommended that the entire nuclear family and members of the extended family who live in the family's home begin family therapy. The grandparents tell you that it is their grandson, rather than their son, who is addicted to prescription painkillers, is the cause of the problem; therefore, they do not have to participate in this group therapy. How should you respond to these grandparents?
Correct Answer: C
Rationale: Addiction affects the entire family system, including extended family members living in the home. Their participation in therapy can help address dysfunctional communication and support the family unit as a whole.
Question 4 of 5
The nurse is caring for a client with a history of burns. Which of the following complications should the nurse monitor for in the acute phase?
Correct Answer: A
Rationale: Hypovolemia is a major complication in the acute phase of burns due to fluid loss.
Question 5 of 5
A client with a history of bipolar disorder is prescribed lithium. The nurse should instruct the client to:
Correct Answer: A
Rationale: Consistent sodium intake prevents lithium toxicity, as sodium fluctuations affect lithium levels.