NCLEX-PN
Next Generation Nclex Questions Overview 3.0 ATI Quizlet Questions
Extract:
Question 1 of 5
Which of the following nursing diagnoses is most appropriate for a client with a new colostomy?
Correct Answer: C
Rationale: Disturbed Body Image is the most appropriate nursing diagnosis for a client with a new colostomy. A new colostomy can significantly impact a person's body image and self-esteem due to the physical changes it brings. This can lead to emotional distress, adjustment issues, and concerns about body image. Excess Fluid Volume, Risk for Aspiration, and Urinary Retention are not directly related to the psychosocial impact of a new colostomy and are therefore not as relevant in this context. While Excess Fluid Volume, Risk for Aspiration, and Urinary Retention are important nursing diagnoses, they are not the priority when considering the psychological and emotional effects of a new colostomy.
Question 2 of 5
Which isolation procedure will be followed for secretions and blood?
Correct Answer: B
Rationale: The correct answer is Standard Precautions. Standard precautions are taken in all situations for all clients and involve all body secretions except sweat. They are designed to reduce the rate of transmission of microbes from one host to another or one source to another. Respiratory Isolation (
Choice
A) is used for diseases transmitted by airborne particles, not secretions and blood. Contact Isolation (
Choice
C) is for clients known or suspected to be infected with microorganisms that can be transmitted by direct or indirect contact. Droplet Isolation (
Choice
D) is used for diseases transmitted by large respiratory droplets expelled during coughing, sneezing, talking, or procedures.
Question 3 of 5
The healthcare provider sustains a needle puncture that requires HIV prophylaxis. Which of the following medication regimens should be used?
Correct Answer: B
Rationale: In the scenario of a needle puncture requiring HIV prophylaxis, the CDC recommends initiating treatment with two non-nucleoside reverse transcriptase inhibitors, unless there is drug resistance. This regimen is preferred over other options such as a single protease inhibitor or two protease inhibitors due to its effectiveness and safety profile in this specific context. Non-nucleoside reverse transcriptase inhibitors are commonly used in post-exposure prophylaxis due to their activity against HIV and lower risk of resistance development compared to other antiretroviral drug classes.
Question 4 of 5
While undergoing fetal heart monitoring, a pregnant Native-American woman requests that a medicine woman be present in the examination room. Which of the following is an appropriate response by the nurse?
Correct Answer: A
Rationale: The correct response is to show cultural awareness and respect the client's request by offering assistance in arranging for the medicine woman to be present. This approach acknowledges the importance of cultural beliefs and practices in the client's care, fostering trust and cooperation.
Choices B, C, and D are inappropriate as they dismiss or belittle the client's cultural beliefs, showing insensitivity and lack of respect, which can negatively impact the nurse-client relationship.
Question 5 of 5
A client with which of the following conditions is at risk for developing a high ammonia level?
Correct Answer: D
Rationale: A client with cirrhosis is at risk for developing a high ammonia level due to impaired liver function. The liver normally converts ammonia into urea for excretion. In cirrhosis, this process is compromised, leading to elevated ammonia levels in the blood. Renal failure, psoriasis, and lupus do not typically cause high ammonia levels. Renal failure affects kidney function, while psoriasis and lupus are autoimmune conditions that do not directly impact ammonia metabolism.