NCLEX Questions, NCLEX Trainer Test 3 Questions, NCLEX-PN Questions, Nurselytic

Questions 157

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Question 1 of 5

Which of the following statements is both a correctly stated nursing diagnosis and a high priority for a 65-year-old client immediately following a modified radical mastectomy and axillary dissection?

Correct Answer: C

Rationale: immediately after surgery, the priority is optimizing the client's comfort

Question 2 of 5

The nurse is assessing a client with suspected appendicitis.

Correct Answer: B

Rationale: Positive rebound tenderness at McBurney’s point is a hallmark of appendicitis, indicating peritoneal irritation. Supine positioning may worsen pain, absent bowel sounds suggest obstruction, and a normal WBC count does not rule out appendicitis.

Question 3 of 5

The nurse is to make several home visits today. All of the visits are within a 5-mile radius. All of the following persons need to be seen. Which person should the nurse visit first?

Correct Answer: A

Rationale: Leg ulcers in a diabetic with peripheral vascular disease pose infection and healing risks, prioritizing wound care. Other needs are less urgent.

Question 4 of 5

The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority?

Correct Answer: B

Rationale: The most common form of TEF is one in which the proximal esophageal segment terminates in a blind pouch and the distal segment is connected to the trachea or primary bronchus by a short fistula. Thus, a priority is maintaining an open airway, preventing aspiration.

Question 5 of 5

A woman who was recently diagnosed with multiple myeloma says to the nurse, 'Why did this happen to me? I've always been a good person. What did I do to deserve this?' What should the nurse do initially?

Correct Answer: C

Rationale: Acknowledging the client's emotional distress validates her feelings, fostering therapeutic communication. Other responses dismiss or redirect her concerns.

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