NCLEX Trainer Test 6

NCLEX Trainer Test 6 Related

Review NCLEX Trainer Test 6 related questions and content

A male client's behavior begins to escalate into aggressive behavior.

The nurse is caring for clients on the psychiatric unit. Suddenly, a male client's behavior begins to escalate into aggressive behavior. It would be MOST important for the nurse to take which of the following actions?

  • A. Utilize an organized team to place the client in seclusion.
  • B. Leave the client alone in his room to identify feelings of anger.
  • C. Redirect the client to a quiet activity to divert his attention and not disturb the other clients.
  • D. Assist the client to identify and express his feelings of increasing anxiety, frustration, and anger.
Correct Answer: D

Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) nurse can be helpful in using psychological/communication strategies before utilizing seclusion (2) leaving the client alone can become potentially dangerous to the client and the property (3) encouraging the client to become involved in a quiet activity might further escalate his frustration and anger because the ability to focus and concentrate is diminished due to an elevated anxiety level (4) correct-as client's anger begins to escalate, nurse can be helpful in using psychological/communication strategies before utilizing seclusion

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The nurse is teaching the client with an ileal conduit regarding skin care to prevent excoriation. In addition to applying a well-fitted collection bag the client should be told to empty the collection bag:

  • A. Every hour
  • B. When it is half full
  • C. Once daily
  • D. When it is one-third full
Correct Answer: D

Rationale: The client should be told to empty the collection bag when it is one-third full. Answer A isn't necessary or feasible, so it is incorrect. Waiting until the collection bag is half full or more as suggested in answers B and C increases the likelihood of skin exposure to urine thereby contributing to excoriation.

What must be the priority consideration for nurses when communicating with children?

  • A. Present environment
  • B. Physical condition
  • C. Nonverbal cues
  • D. Developmental level
Correct Answer: D

Rationale: While each of the factors affects communication, the nurse recognizes that developmental differences have implications for processing and understanding information. Consequently, a child's developmental level must be considered when selecting communication approaches.

The nurse is teaching a client with a new diagnosis of asthma about fluticasone (Flovent). Which of the following instructions should the nurse include?

  • A. Use the inhaler as needed for shortness of breath.
  • B. Rinse the mouth after use.
  • C. Stop the medication if symptoms improve.
  • D. Avoid regular asthma follow-ups.
Correct Answer: B

Rationale: Rinsing the mouth prevents oral thrush, a fluticasone side effect. Options A, C, and D are incorrect.

A patient is scheduled for electro-convulsive therapy treatment scheduled in the morning. What must the evening nurse do to provide the client ECT treatment possible?

  • A. Patient signs an informed consent form
  • B. Patient is given morning medications
  • C. Patient gets a good night's sleep
  • D. Patient has a good breakfast
Correct Answer: A

Rationale: An informed consent is required prior to surgery.

The nurse checks for placement of a nasogastric (NG) tube before beginning a tube feeding for a client.

Which of the following results would indicate to the nurse that the tube feeding can begin?

  • A. A small amount of white mucus is aspirated from the NG tube.
  • B. The pH of the contents removed from the NG tube is 3.
  • C. No bubbles are seen when the nurse inverts the NG tube in water.
  • D. The client says he can feel the NG tube in the back of his throat.
Correct Answer: B

Rationale: Strategy: Determine how the answers relate to a tube feeding. (1) mucus may be from lungs (2) correct-stomach contents are acidic (3) not a safe way to check placement (4) not a reliable indication

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