NCLEX-RN
NCLEX RN Test Bank with Rationales Questions
Extract:
Question 1 of 5
To maintain a safe milieu while addressing the needs of the cognitively impaired clients on the unit, which interventions should the psychiatric nurse implement? Select all that apply.
Correct Answer: A,B,C,D
Rationale:
To maintain a safe milieu for cognitively impaired clients, the nurse should use distracting techniques to redirect inappropriate behaviors, be consistently visible and available to provide reassurance and support, provide reality orientation to help clients maintain awareness of their surroundings, and anticipate client needs to prevent distress or agitation. Segregating potentially volatile clients is not typically recommended as it may increase feelings of isolation or stigmatization; instead, managing their behavior through de-escalation and individualized care is preferred.
Question 2 of 5
The nurse is caring for a client with a history of seizures. Which precaution should be implemented?
Correct Answer: B
Rationale: Suction equipment is essential to maintain airway patency during a seizure, a critical safety precaution.
Question 3 of 5
Which nursing assessment findings indicate normal vital signs in a newborn infant?
Correct Answer: C
Rationale: The normal pulse rate for a newborn is 120 to 160. The normal respiratory rate for a newborn infant is 30 to 60 breaths per minute.
Therefore, the other options are incorrect.
Question 4 of 5
An 80-year-old client with severe kidney damage is placed on life support and dialysis. Care decisions are being made by his wife, who is showing signs of early Alzheimer's disease. The client's daughter arrives from out of town with a copy of the client's living will, which states that the client did not want to be on life support. The nurse should:
Correct Answer: A
Rationale: Informing the physician about the living will ensures that the client's wishes are addressed promptly.
Question 5 of 5
A client with a burn injury is prescribed silver sulfadiazine. What should the nurse monitor for?
Correct Answer: B
Rationale: Silver sulfadiazine can cause leukopenia, so monitoring white blood cell counts is essential.