NCLEX-PN
Basic Care and Comfort NCLEX Questions
Extract:
Question 1 of 5
A pregnant client has congenital heart disease. The nurse should expect to see which alterations in this client's diet during pregnancy?
Correct Answer: B
Rationale: Caffeine and sodium restrictions are necessary to reduce cardiac strain and fluid retention in a pregnant client with heart disease, avoiding exacerbation of her condition.
Question 2 of 5
A nurse is working in a pediatric clinic and a mother brings in her 13 month old child who has Down Syndrome. The mother reports, 'My child's muscles feel weak and he isn't moving well. My RN friend checked his reflexes and she said they are diminished.' Which of the following actions should the nurse take first?
Correct Answer: D
Rationale: An atlanto-axial dislocation may have occurred, common in Down Syndrome. Positioning the child's neck in a neutral c-spine posture is the first step to prevent further injury, followed by contacting the doctor.
Question 3 of 5
A 17-year-old female was raped by a young man in her neighborhood. She is in the Emergency Department for evaluation and tests. After the procedure is completed, a rape crisis counselor (nurse specialist) talks to the client in a conference room regarding the rape. Implementing counseling by the nurse specialist for the raped victim represents:
Correct Answer: B
Rationale:
Choice 2 is part of the Crisis Intervention Model. Counseling by a nurse specialist at the time of a stressful event (rape) can strengthen the client's coping. A nurse specialist in rape crisis intervention is educationally prepared in counseling and crisis intervention specific to rape victims.
Question 4 of 5
The nurse is caring for the newly admitted male client who is unconscious. The UAP asks if the client should be shaved. What is the nurse's best response?
Correct Answer: A
Rationale: A: Removal of facial hair varies based on personal and cultural preferences, which should be assessed first. B: Bathing order is irrelevant without preferences. C: Electric razors are safe but preferences are unknown. D: Shaving does not require a doctor's order.
Question 5 of 5
A client with massive chest and head injuries is admitted to the ICU from the Emergency Department. All of the following are true except:
Correct Answer: C
Rationale: The client's legally responsible party may make the decision for organ donation if the client is unable to do so. The donor (or legally responsible party for the donor), the physician, and the organ-procurement organization are all involved in the process regarding whether organ donation is appropriate for a specific donor.