NCLEX-RN
Planning Questions
Extract:
Question 1 of 5
A client who was a victim of a gunshot incident states, 'I feel like I am losing my mind. I keep hearing the gunshots and seeing my friend lying on the ground.' Which strategy should the nurse include when initially formulating a therapeutic relationship?
Correct Answer: C
Rationale: When developing a therapeutic relationship, it is important to acknowledge and validate the client's feelings. Although teaching the client relaxation techniques may be helpful at some point, it is not related to the subject of the question. Options 2 and 4 are nontherapeutic techniques, and they do not promote a therapeutic relationship.
Question 2 of 5
The home care nurse is preparing a plan of care for a client diagnosed with Ménière's syndrome. Which nursing intervention should the nurse include to assist the client with controlling vertigo?
Correct Answer: C
Rationale: Ménière's syndrome refers to dilation of the endolymphatic system by overproduction or decreased resorption of endolymphatic fluid. The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Clients are advised to stop smoking because of its vasoconstrictive effects. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed.
Question 3 of 5
The nurse is planning care for an infant who has a diagnosis of hypertrophic pyloric stenosis and is scheduled for surgery. Which intervention should the nurse include to meet the infant's preoperative needs?
Correct Answer: C
Rationale: Preoperatively, important nursing responsibilities for the child with hypertrophic pyloric stenosis include monitoring the IV infusion, intake, output, and weight and obtaining urine specific gravity measurements. Additionally, weighing the infant's diapers provides information regarding output. Enemas until clear would further compromise the fluid volume status. Preoperatively, the infant receives nothing by mouth unless otherwise prescribed by the primary health care provider.
Question 4 of 5
The nurse is informed that a newborn infant whose mother is Rh negative will be admitted to the nursery. When planning care for the infant's arrival, which action should the nurse take?
Correct Answer: A
Rationale:
To further plan for the newborn infant's care, the infant's blood type and direct Coombs' results must be known. Umbilical cord blood is taken at the time of delivery to determine blood type, Rh factor, and antibody titer (direct Coombs' test) of the newborn infant. The nurse should obtain these results from the laboratory. Options 2 and 3 are inappropriate at this time, and additional data are needed to determine whether these actions are needed. Option 4 is incorrect because vitamin K is given to prevent hemorrhagic disease of the newborn infant.
Question 5 of 5
The nurse is preparing to assist in the administration of a chemotherapeutic agent via intraperitoneal (IP) therapy. In which position should the nurse plan to place the client before administering this therapy?
Correct Answer: B
Rationale: IP therapy is the administration of chemotherapeutic agents into the peritoneal cavity. This therapy is used for intra-abdominal malignancies such as ovarian and gastrointestinal tumors that have moved into the peritoneum after surgery. The client should be placed in a semi-Fowler's position for this infusion because the client may experience nausea and vomiting caused by increasing pressure on the internal organs. Additionally, this treatment may also place pressure on the diaphragm. The positions indicated in the rest of the options would increase pressure in the peritoneal cavity.