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Questions 158

NCLEX-RN

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Extract:


Question 1 of 5

Which client should be assigned to the nursing assistant?

Correct Answer: C

Rationale: The elderly client four days post-thyroidectomy is stable and suitable for a nursing assistant’s care (e.g., basic hygiene, ambulation). The other clients require skilled nursing due to critical conditions (cervical fracture, meningitis, recent thoracotomy).

Question 2 of 5

The nurse is formulating a plan of care for a client with a goiter. The priority nursing diagnosis for the client with a goiter is:

Correct Answer: D

Rationale: A large goiter can compress the trachea, posing a risk for ineffective airway clearance, which is a priority due to its potential to impair breathing.

Question 3 of 5

A 20-year-old female client delivers a stillborn infant. Following the delivery, an appropriate response by the labor nurse to the question, 'Why did this happen to my baby?' is:

Correct Answer: D

Rationale: The mother and the father require Wsupport; the nurse should not minimize their grief in this situation. Attachment to this infant occurs during the pregnancy for both the mother and father. Another child cannot replace this child. Attachment to this infant occurs during the pregnancy for both the mother and father. Siblings will not replace their feelings or minimize their loss of this infant. Holding and viewing the infant decreases denial and may facilitate the grief process. The nurse should prepare family members for how the infant appears ('she is bruised') and provide support.

Question 4 of 5

A client with a history of trigeminal neuralgia is admitted with complaints of facial pain. The nurse should give priority to:

Correct Answer: A

Rationale: Trigeminal neuralgia causes severe facial pain, so administering analgesics is the priority to relieve discomfort.

Question 5 of 5

The nurse is caring for a client with a history of congestive heart failure. The nurse should give priority to:

Correct Answer: A

Rationale: Congestive heart failure increases the risk of arrhythmias due to cardiac strain, making monitoring for arrhythmias a priority to prevent sudden cardiac events.

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