Nclex Exam Cram Practice Questions - Nurselytic

Correct Answer: D

Rationale: Negligent acts in nursing include various errors that can harm the client, such as medication errors, intravenous therapy errors, burns, falls, failure to use aseptic technique, failure to provide adequate monitoring, and failure to report significant changes in a client's condition. In this scenario, using clean gloves to change a gastrostomy tube dressing is a negligent act because sterile gloves should be used when changing a dressing over broken skin.

Choices A, B, and C are not negligent acts as they involve appropriate nursing actions: giving a verbal report, checking neurological signs, and contacting a healthcare provider about a change in a client's blood pressure.

Correct Answer: A

Rationale: When assessing a client with a cast, it is crucial to check for capillary refill to ensure adequate circulation. Warm toes indicate good circulation, while the absence of discomfort suggests the cast is not causing any pain or undue pressure on the client.
Therefore, choices B, C, and D are incorrect as they do not address the essential components of assessing a client with a cast.

Correct Answer: B

Rationale: Mammography is specifically used to detect tumors or abnormal growths, especially in breast tissue. It is not a tool for identifying pain, edema, or epilepsy.
Therefore, the correct answer is 'tumor.' Pain is a symptom, edema is swelling, and epilepsy is a neurological disorder; none of these are conditions typically detected through mammography.

Correct Answer: B

Rationale: The correct answer is to promote healthy nutritional practices. This goal focuses on preventive measures to address the client's nutritional risk. Providing oxygen (
Choice
A) is not directly related to addressing nutritional problems. Treating complications of malnutrition (
Choice
C) involves addressing the consequences rather than preventing or managing the nutritional problems. Increasing weight (
Choice
D) would only be appropriate if the client is underweight; it does not address the broader aspect of promoting overall healthy nutritional practices.

Correct Answer: A

Rationale: The correct action for a client with major head trauma receiving bolus enteral feeding is to measure intake and output (I&O). Enteral feedings are hyperosmotic agents that can cause fluid shifts. Monitoring I&O is crucial to assess fluid balance, ensuring that input matches output. Checking albumin levels (choice
B) is important for assessing nutritional status but is not the immediate priority in this situation. Monitoring glucose levels (choice
C) is also important but not as critical as measuring I&O in this context. Increasing enteral feeding (choice
D) should only be done based on a healthcare provider's order after assessing the patient's condition, not as the most important nursing order at this time.