NCLEX-RN
Free NCLEX RN Exam Practice Questions Questions
Extract:
Question 1 of 5
Which interventions should the nurse use to assist the client with grandiose delusions? Select all that apply.
Correct Answer: A,B,C
Rationale:
To manage grandiose delusions, the nurse should accept the client without reinforcing the delusion, focus on the underlying feelings, and redirect to reality-based topics. Confronting beliefs or limiting interaction to reality-based moments can escalate agitation or alienate the client.
Question 2 of 5
A client who has been recently diagnosed with unsuccessful immunodiffence (MIDS) inquires about hospice services. The nurse explains that hospice care is appropriate:
Correct Answer: A
Rationale: Hospice care is appropriate for clients with a terminal illness and a prognosis of weeks to months, regardless of the specific diagnosis. It is not limited to cancer or all AIDS stages, nor solely based on readiness to discuss prognosis.
Question 3 of 5
The nurse performs an assessment on a client with cancer and notes that the client is receiving pain medication via this type of catheter. (Refer to the figure.) What should the nurse document that the client has?
Correct Answer: A
Rationale: An epidural catheter is placed in the epidural space. The epidural space lies between the dura mater and the vertebral column. When an opioid is injected into the epidural space, it binds to opiate receptors located on the dorsal horn of the spinal cord and blocks the transmission of pain impulses to the cerebral cortex of the brain. Because the opioid does not cross the blood-brain barrier, pain relief results from drug levels in the spinal cord rather than in the plasma, with little central or systemic distribution of the medication. A Hickman catheter is a vascular access device that is surgically inserted, tunneled through the subcutaneous tissue, and is used to manage long-term intravenous therapy. A CVC is inserted into a large vein (typically the internal or external jugular or the superior vena cava) that leads to the right atrium of the heart. A PCA pump is the device that allows the client to self-administer pain medication.
Question 4 of 5
A client was admitted to the surgical unit after right total knee arthroscopy performed 2 hours earlier. Which surgeon's prescription requires clarification?
Correct Answer: A
Rationale: The knee is immobilized by a compression dressing to keep the knee in extension immediately after the operation. The nurse should clarify a prescription to keep the knee slightly flexed. Pain control by use of patient-controlled analgesia, use of compression devices to reduce the risk of thromboembolism, and physical therapy to begin isometric quadriceps exercises are expected prescriptions after total knee arthroscopy surgery.
Question 5 of 5
A client with a history of gout is prescribed probenecid. The nurse should instruct the client to:
Correct Answer: A, B
Rationale: Increased fluid intake prevents kidney stones, and aspirin can reduce probenecid's effectiveness.