Nclex Exam Cram Practice Questions - Nurselytic

Correct Answer: D

Rationale: When caring for clients with cancer who are taking opioids, nurses need to assess for tolerance, constipation, and sedation as these are common side effects of opioid use. Addiction, however, is not a primary concern when treating pain in terminally ill clients. Terminally ill patients are usually not at risk of developing addiction to opioids due to their short life expectancy and the focus on pain management rather than the potential for addiction.
Therefore, the correct answer is 'addiction.'

Choices A, B, and C are essential considerations when managing clients on opioids for pain control.

Correct Answer: B

Rationale: The correct answer is B: Secondary prevention. Hearing screening for prematurely born infants falls under secondary prevention, which aims to identify and treat a condition in its early stages to prevent further complications. Primary prevention (choice
A) focuses on preventing the disease from occurring, while tertiary prevention (choice
C) involves managing complications and preventing disability.
Choice D, disability prevention, is not a recognized category of prevention. In this context, the screening helps in early identification of hearing loss, allowing for timely intervention to prevent further impairment or complications, aligning with the principles of secondary prevention.

Correct Answer: A

Rationale: The correct answer is hepatitis A. Hepatitis A does not produce a carrier state after its acute phase. It is transmitted via contaminated water or food through the oral-fecal route and is not blood-borne. Hepatitis B, choice B, can lead to a carrier state where the person remains infectious despite being asymptomatic. Hepatitis C, choice C, can also result in a chronic carrier state. Hepatitis D, choice D, is an incomplete virus that requires hepatitis B to replicate; it does not lead to a carrier state on its own.

Correct Answer: A

Rationale: In this situation, the best approach for the nurse is to ask whether another individual wants to be the client's support person. This empowers the client to choose someone to be with her until her family can join her, providing the needed support and comfort. Assuring her that a nursing staff member will be with her at all times (
Choice
B) may not fully address her emotional needs for familiar support. Telling her you will try to locate her family (
Choice
C) may not be feasible in the immediate situation and may not provide immediate emotional support. While reinforcing the woman's confidence in her own abilities (
Choice
D) is important, it may not fully address her current need for emotional support and presence of a companion.

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.