2024 Nclex Questions - Nurselytic

Correct Answer: B

Rationale: The correct answer is telling the client that the medication will change the color of the urine. Rifampin can change the color of the urine and body fluid. Teaching the client about these changes is important as the client might think this is a complication. Answer A is incorrect because there is no specific requirement to take rifampin with juice. Answer C is incorrect because rifampin should be taken at consistent times, not necessarily before going to bed. Answer D is incorrect as rifampin should be taken regularly as prescribed, not based on symptoms like night sweats.

Correct Answer: A

Rationale: Viewing crisis intervention as the first step in solving bigger problems is essential in a nurse who assists clients during crises. This approach focuses on addressing the immediate crisis first, which can potentially prevent the escalation of bigger problems. Wanting to help clients solve all problems identified (
Choice
B) may not be feasible or necessary during a crisis situation where immediate intervention is crucial. Taking an active role in guiding the process (
Choice
C) is important, but the primary focus should be on crisis intervention. Feeling that work requires identification with all of a client's problems (
Choice
D) may lead to a lack of focus on the immediate crisis at hand.

Correct Answer: D

Rationale: In cases where elderly clients deny abuse and refuse assistance, it is crucial for the nurse to respect their autonomy while also ensuring their safety. Educating the client about available services is the appropriate action as it empowers the client with information without imposing any decisions on them. It allows the client to make informed choices regarding their well-being. Reporting the incident to the authorities (
Choice
B) may be necessary if there is immediate danger, but in this scenario, the client denies abuse. Arranging an appointment with the client's family (
Choice
C) may not be appropriate without the client's consent or in cases where the family might be involved in the abuse. Simply doing nothing (
Choice
A) is not the best course of action as the nurse should still provide support and resources to the client.

Correct Answer: A

Rationale: The purpose of a contract between a nurse and a client is to specify the participation and responsibilities of both parties. It outlines the expectations, contributions, and duties of each party involved in the professional relationship. This ensures clarity and mutual understanding.
Choice B is incorrect as contracts do not indicate feeling tone but rather focus on the professional aspects.
Choice C is incorrect because while contracts are legally binding, their primary purpose is not to prevent premature termination but to establish guidelines.
Choice D is incorrect as contracts focus more on responsibilities and participation rather than specific roles.

Correct Answer: C

Rationale: The correct answer is to check the pulse. Theodur is a bronchodilator used in asthma treatment, and one of the side effects is tachycardia (increased heart rate).
Therefore, it is essential to assess the pulse rate before administering Theodur to monitor for any potential tachycardia. Checking urinary output (
Choice
A), blood pressure (
Choice
B), and temperature (
Choice
D) are not directly related to the immediate side effects of bronchodilators like Theodur in this context, making them unnecessary assessments.