NCLEX RN Practice Questions With Rationale - Nurselytic

Correct Answer: D

Rationale: During school-age years, children typically gain about 5.5 pounds per year and increase in height by about 2 inches annually. This steady growth pattern is expected between ages 2 to 10 years.
Choice A is incorrect as children at this stage are expected to gain weight and grow in height.
Choice B is incorrect as there should be noticeable changes in body appearance due to growth.
Choice C is incorrect as a progressive height increase of 4 inches each year is not typical during the school-age years.

Correct Answer: C

Rationale: The most appropriate and caring response is to perform a pain assessment and administer the pain medication that has been ordered. Regardless of personal feelings about any given situation, the nurse's responsibility is to provide unbiased, appropriate, and supportive care, as stated in the American Nurses Association (AN
A) Code of Ethics.
Choice A is not appropriate as it disregards the patient's immediate need for pain relief.
Choice B may escalate the situation and is not the priority in this case.
Choice D is not the immediate action needed to address the patient's pain and distress.

Correct Answer: D

Rationale: The most therapeutic response to Rachel's statement is to provide non-judgmental support and hope. By acknowledging the patient's feelings of shame and embarrassment and offering help and understanding, the nurse can help Rachel maintain her self-esteem.
Choice A is not therapeutic as it may unintentionally convey guilt or further shame.
Choice B is judgmental and confrontational, which can create a barrier to open communication.
Choice C is dismissive and does not address Rachel's emotional state. The correct response (
Choice
D) acknowledges the patient's struggle, offers support, and conveys empathy, aligning with the nurse's role to treat all patients with respect and dignity in challenging situations.

Correct Answer: C

Rationale: The correct response is to ensure that the patient fully understands the nature of the surgery they are about to undergo. If the patient expresses uncertainty about the procedure they signed consent for, it indicates a lack of informed consent, which is essential before any surgery. By requesting the nurse anesthetist to return and provide a more detailed explanation, the patient can make an informed decision.

Choices A, B, and D do not address the issue of the patient's lack of understanding and the need for informed consent, making them incorrect. Option C is the best course of action to rectify the situation and ensure the patient's understanding and consent are properly obtained.

Correct Answer: B

Rationale: Supervision in nursing requires key components to ensure effective management. Tasks to be delegated or supervised must align with the nurse's scope of practice to maintain safety and quality care. Adequate time for staff assignment development is essential for efficient workflow. Policies governing nursing practice provide a framework for safe and standardized care. However, the statement 'The necessary tasks require repeated assessments' is not an essential component of supervision. Tasks should be clear, achievable, and not necessitate repeated assessments, as this would impede delegation and efficient completion. Repeated assessments may indicate unclear task delegation or inadequate initial assessment, which should be avoided in effective supervision.