Questions 150

NCLEX-RN

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Question 1 of 5

You are a home health nurse caring for an elderly client in their home. They have children and grandchildren but they live far from the client and they typically visit with your clients once to two times a year. The elderly man is beginning to show some of the signs of Alzheimer's disease dementia. The wife is also 88 years of age and has had a stroke which has left her with left sided weakness, but she is willing to help her husband and to maintain his safety. What kind of support should you give the wife in terms of her role caring for her husband?

Correct Answer: B

Rationale: Educating the wife about Alzheimer's disease and promoting the husband's independence as much as possible supports safety and dignity while respecting her role as a caregiver with physical limitations.

Question 2 of 5

The registered nurse, prior to the delegation of tasks to other members of the nursing care team, evaluates the ability of staff members to perform assigned tasks for the position as based on which legal consideration?

Correct Answer: C

Rationale: Delegation of tasks by a registered nurse must comply with state statutes , which define the scope of practice and delegation authority for nurses and other healthcare team members within each state. These laws ensure that tasks are delegated to individuals who are legally qualified to perform them.

Question 3 of 5

The nurse has received the client assignment for the day. Which client should the nurse care for first?

Correct Answer: C

Rationale: The client with a cast who experiences numbness in the fingers should be seen first because this could be a symptom of compartment syndrome. Compartment syndrome creates an emergency situation when it does occur. Within 4 to 6 hours after the onset of compartment syndrome, neurovascular and muscle damage are irreversible if treatment is not provided. The limb can become useless in 24 to 48 hours. It would be expected that the client with a wound infection will have an elevation in body temperature. A client on anticoagulant therapy for treatment of a deep vein thrombosis who experiences bleeding gums when brushing teeth should be evaluated but is not the priority. A respiratory rate of 22 breaths per minute in the client with COPD is considered normal.

Question 4 of 5

A client with a history of peptic ulcer disease is prescribed ranitidine (Zantac). The nurse should explain that this medication works by:

Correct Answer: B

Rationale: Ranitidine, an H2-receptor blocker, reduces gastric acid secretion, helping to heal peptic ulcers.

Question 5 of 5

The client with borderline personality disorder spends much time around the nurse's station, making numerous minor requests. The nurse interprets these behaviors as indicating which of the following?

Correct Answer: A

Rationale: Frequent requests and presence at the nurse's station in borderline personality disorder often reflect fears of abandonment and attention-seeking behaviors, characteristic of the disorder.

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