NCLEX-RN
NCLEX RN Exam Review Answers Questions
Extract:
Question 1 of 5
You are attempting to teach the wife of a Greek patient how to administer his gastrostomy tube feedings once he returns home. She smiles and nods through your explanations, but when you ask her for a return demonstration, she looks confused and shakes her head. Her daughter enters the room and states that she does not speak English. What would be most helpful in this situation?
Correct Answer: B
Rationale: Teaching both the patient's wife and the daughter is the best option in this situation. The daughter may not always be available, and the wife is eager to care for her husband at home. While a hospital interpreter is often preferred, asking the daughter to interpret is a good alternative. This approach allows the daughter to receive instruction and reinforce it for herself as she translates it to her mother. Contacting a home health agency may not be necessary if family members are willing and able to assist. Providing a pamphlet with detailed instructions would not be as effective in ensuring the wife fully understands the procedure and can carry it out correctly.
Question 2 of 5
Which of the following is an example of restorative care?
Correct Answer: B
Rationale: Restorative care involves assisting clients in regaining or maintaining their highest possible level of function. This type of care focuses on promoting self-care and independence by helping clients perform activities that enhance their functional abilities. In this scenario, a nurse who assists a client with developing a bladder-retraining program is engaging in restorative care by helping the client regain bladder function.
Choices A, C, and D do not represent restorative care. Teaching a new mother how to breastfeed her infant (
Choice
A) is an example of educative care, placing an allergy wristband (
Choice
C) is a safety measure, and contacting a client's family to update them on surgery (
Choice
D) is related to communication and support, not restorative care.
Question 3 of 5
A client with schizophrenia seems to stop focusing during a conversation with a nurse and begins looking at the ceiling and talking to themselves. Which of the following actions should the nurse take?
Correct Answer: B
Rationale: When a client with schizophrenia experiences a break in reality like staring at the ceiling and talking to themselves, the nurse should ask directly about the hallucination, as stated in choice B. By doing so, the nurse can assess the situation, identify the client's needs, and evaluate any potential risk for injury.
Choices A, C, and D are incorrect. Stopping the interview (choice
A) may not address the immediate concern of the hallucination. Providing false reassurance (choice
C) or ignoring the behavior (choice
D) does not actively address the client's altered perception of reality.
Question 4 of 5
A client with a new prescription for lithium carbonate for bipolar disorder is being educated by a nurse on early indications of toxicity. The nurse should include which of the following manifestations in the teachings?
Correct Answer: B
Rationale: Polyuria is a crucial early indication of lithium toxicity. It results from the drug's effect on the kidneys, leading to increased urine output. This is a significant symptom to monitor as it can indicate potential toxicity. Constipation, rash, and tinnitus are not typically associated with early indications of lithium toxicity. Constipation is more commonly seen as a side effect of some medications, while rash and tinnitus are not specific indicators of lithium toxicity.
Question 5 of 5
Which of the following interventions should be prioritized in the care of the suicidal client?
Correct Answer: A
Rationale: accessibility of the means of suicide increases the lethality. Allowing a patient to express feelings and setting a no suicide contract are interventions for suicidal client but blocking the means of suicide is priority. Increasing self esteem is an intervention for depressed clients but not specifically for suicide.