NCLEX-RN
Saunders NCLEX RN Practice Questions Questions
Extract:
Question 1 of 5
Which of the following is an example of the intervention phase of the individualized nursing care plan for a client who receives a colostomy after a bowel resection?
Correct Answer: B
Rationale: The correct answer is B. Instructing the client about how to care for his colostomy stoma is an example of the intervention phase as it involves providing specific guidance to the client on post-operative care. This intervention directly addresses the client's needs post-colostomy and helps promote optimal healing and adjustment.
Choice A is part of the assessment phase, which occurs before the intervention phase.
Choice C involves goal-setting, which is part of the planning phase.
Choice D pertains to discharge planning, which is part of the evaluation phase.
In summary,
Choice B is the correct answer because it aligns with the intervention phase of the nursing care plan, focusing on providing necessary education and support to the client regarding colostomy care.
Question 2 of 5
At the beginning of her shift in a long-term care facility, which of the following clients should a nurse check on first?
Correct Answer: C
Rationale: The correct answer is C: An 82-year-old woman who needs IV antibiotics. Checking on this client first is crucial because IV antibiotics are time-sensitive and require proper administration to ensure the effectiveness of treatment. Delaying or missing a dose can have serious consequences for the client's health. The other choices, while important, can be prioritized after attending to the client needing IV antibiotics. A: The 91-year-old man needing help eating breakfast can wait a bit longer. B: The 86-year-old man who has been incontinent can be addressed after the client needing IV antibiotics. D: The 75-year-old man recovering from an injury and needing an ice pack can also be attended to after the client requiring IV antibiotics.
Question 3 of 5
A patient is being seen in the crisis unit reporting that poison letters are coming in the mail. The patient has no history of psychiatric illness. Which group of the following medications would the patient most likely be started on?
Correct Answer: A
Rationale: The correct answer is A: Aripiprazole (Abilify). In this scenario, the patient is experiencing paranoid delusions, a symptom commonly associated with psychotic disorders. Aripiprazole is an atypical antipsychotic that is often used to treat symptoms of psychosis, including delusions. It is a preferred choice because it has a lower risk of side effects compared to typical antipsychotics like fluphenazine. Risperidone, another atypical antipsychotic, could also be considered, but aripiprazole is often preferred due to its side effect profile. Fluoxetine, an antidepressant, is not the ideal choice for treating psychotic symptoms.
Therefore, aripiprazole is the most appropriate medication in this case.
Question 4 of 5
A client is found lying on the floor near the bathroom door, stating, 'I thought I could get up on my own.' What information must the nurse document in this situation?
Correct Answer: A
Rationale: The correct answer is A because documenting the client's own words provides direct evidence of their condition and thought process at the time of the incident. This helps in understanding the client's perspective and decision-making, which is crucial for providing appropriate care and preventing future falls.
Choice B is incorrect because while it may be important to document how the fall happened and when the physician was notified, it does not directly capture the client's own words and thoughts.
Choice C is incorrect as it focuses on the conditions of the room rather than the client's own account of the situation.
Choice D is also incorrect as it pertains to the client's medical history and medications, which are important but not directly relevant to documenting the client's immediate situation and actions.
Question 5 of 5
A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the healthcare provider ordering:
Correct Answer: B
Rationale: The correct answer is B: Vena caval interruption. In this scenario, the client has a history of recurrent pulmonary embolism, indicating a high risk for further episodes. Vena caval interruption, such as with an inferior vena cava filter, is a preventive measure to reduce the risk of pulmonary embolism recurrence by trapping blood clots before they reach the pulmonary circulation. This intervention is indicated when anticoagulation alone is not sufficient to prevent further emboli. Pulmonary embolectomy (
A) is a surgical procedure to remove a clot from the pulmonary artery and is typically reserved for massive, life-threatening embolisms. Increasing coumadin therapy (
C) to achieve a higher INR may increase bleeding risk without necessarily preventing future emboli. Thrombolytic therapy (
D) is reserved for acute, large emboli causing hemodynamic instability.