NCLEX Questions, RN NCLEX Practice Questions Questions, NCLEX-RN Questions, Nurselytic

Questions 149

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Extract:


Question 1 of 5

Which one of the following situations represents a maturational crisis for the family?

Correct Answer: A

Rationale: A 4-year-old entering nursery school is a maturational crisis, as it involves a normal developmental transition that can stress family dynamics.

Question 2 of 5

The nurse is caring for a client with a malignancy. The classification of the primary tumor is Tis. The nurse should plan care for a tumor:

Correct Answer: B

Rationale: Tis indicates a tumor in situ, meaning it is noninvasive and confined to its original site, requiring specific care planning.

Question 3 of 5

The nurse is caring for a client with a history of schizophrenia who is experiencing auditory hallucinations. Which of the following interventions should the nurse implement?

Correct Answer: B

Rationale: listening to music can distract the client and reduce the intensity of auditory hallucinations

Question 4 of 5

A client with a tracheostomy is exhibiting difficulty breathing, and respirations are increasingly noisy. Secretions are very thick. Which of the following initial interventions is most indicated?

Correct Answer: A

Rationale: Thick secretions causing noisy respirations and breathing difficulty indicate the need for increased humidification to thin secretions and suctioning to clear the tracheostomy tube (
A). Notifying the physician (
B) or encouraging coughing (
C) is secondary, and irrigation (
D) is not typically the initial step.

Question 5 of 5

A client with $B$ positive blood is scheduled for a transfusion of whole blood. Which finding requires nursing intervention?

Correct Answer: B

Rationale: Transfusing Rh-negative blood to an Rh-positive client can cause incompatibility reactions, requiring intervention to ensure Rh compatibility.

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