NCLEX Questions, NCLEX Trainer Test 10 Questions, NCLEX-PN Questions, Nurselytic

Questions 227

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Question 1 of 5

The nurse is receiving a bedside report from another nurse. The nurse giving the report begins to talk about another client. Which action by the nurse receiving the report is MOST appropriate?

Correct Answer: A

Rationale: client confidentiality is being violated, nurse should intervene to protect client

Question 2 of 5

At approximately 6 PM, the nurse begins to open the nurses' notes for the evening shift. The last entry is noted for 1 PM, and there is no signature. The MOST appropriate nursing response is to

Correct Answer: C

Rationale: day nurse can make a 'late entry' to add any additional information

Question 3 of 5

The nursing care plan for a five-year-old with a closed head injury should contain which of the following?

Correct Answer: B

Rationale: early signs of increased intracranial pressure are alterations in orientation

Question 4 of 5

A three-month-old patient is experiencing increased intracranial pressure (ICP). Which of the following assessment findings should the nurse report to the physician?

Correct Answer: B

Rationale: sign of increased intracranial pressure

Question 5 of 5

The nurse is caring for a client who is postoperative day 1 following a total knee replacement. Which of the following findings should the nurse report to the physician immediately?

Correct Answer: B

Rationale: swelling and warmth may indicate infection or a deep vein thrombosis, which requires immediate attention

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