NCLEX-RN
NCLEX RN Test Bank Questions PDF Questions
Extract:
Question 1 of 5
You are caring for a client at the end of life. The client tells you that they are grateful for having considered and decided upon some end of life decisions and the appointments of those who they wish to make decisions for them when they are no longer able to do so. During this discussion with the client and the client's wife, the client states that 'my wife and I are legally married so I am so glad that she can automatically make all healthcare decisions on my behalf without a legal durable power of attorney when I am no longer able to do so myself' and the wife responds to this statement with, 'that is not completely true. I can only make decisions for you and on your behalf when these decisions are not already documented on your advance directive.' How should you, as the nurse, respond to and address this conversation between the husband and wife and the end of life?
Correct Answer: C
Rationale: The client's statement reflects a misunderstanding that a spouse automatically assumes the role of durable power of attorney for healthcare decisions without a legal designation. The wife's response is correct in that an advance directive takes precedence, and a durable power of attorney is only effective for decisions not covered by the advance directive. The nurse should recognize the client's knowledge deficit and plan education to clarify the roles of advance directives and durable power of attorney, as stated in option C.
Question 2 of 5
The nurse is preparing to administer a dose of warfarin (Coumadin) to a client. The client's International Normalized Ratio (INR) is 4.0. What should the nurse do?
Correct Answer: B
Rationale: An INR of 4.0 is above the therapeutic range (2-3), indicating a risk of bleeding, so the nurse should hold the dose and notify the physician.
Question 3 of 5
The nurse establishes the goal of preventing the development of a stress ulcer in a burn client. Which of the following interventions would most likely contribute to the achievement of this goal?
Correct Answer: C
Rationale: Prophylactic antacids or H2 receptor antagonists reduce gastric acid, preventing stress ulcers in burn patients, who are at high risk due to stress response.
Question 4 of 5
A client is scheduled for a creatinine clearance test. Which one of the following preparations is appropriate for the nurse to make?
Correct Answer: A
Rationale: A creatinine clearance test requires a 24-hour urine collection to assess kidney function accurately, making this the appropriate preparation.
Question 5 of 5
The nurse is caring for a client with a new diagnosis of glaucoma. Which medication class should the nurse expect to administer?
Correct Answer: A
Rationale: Beta-blockers, such as timolol, reduce intraocular pressure in glaucoma by decreasing aqueous humor production, the primary treatment goal.