NCLEX-PN
Best NCLEX Next Gen Prep
1. What is an appropriate nursing goal for a client at risk for nutritional problems?
- A. provide oxygen
- B. promote healthy nutritional practices
- C. treat complications of malnutrition
- D. increase weight
Correct answer: B
Rationale: Promoting healthy nutritional practices is an appropriate nursing goal for a client at risk for nutritional problems as it focuses on preventive measures to address the risk of nutritional issues. Choice A is incorrect because providing oxygen is not related to addressing nutritional problems. Choice C is incorrect as it involves treating the consequences rather than preventing nutritional problems. Choice D is incorrect because increasing weight is only suitable if the client is underweight, not as a general preventive measure.
2. When performing an abdominal assessment, what is the correct order of the tasks?
- A. inspect, percuss, palpate, auscultate
- B. inspect, palpate, percuss, auscultate
- C. inspect, auscultate, percuss, palpate
- D. inspect, palpate, auscultate, percuss
Correct answer: C
Rationale: The correct order of tasks when performing an abdominal assessment is to first inspect the abdomen visually, then auscultate to assess bowel sounds without altering them, followed by percussing to assess the presence of tympany or dullness, and finally palpating to feel for any tenderness, masses, or organ enlargement. Placing palpation or percussion before auscultation, as in choices A, B, and D, can affect the bowel sounds and examination findings, making them incorrect sequences.
3. The goals of palliative care include all of the following except:
- A. giving clients with life-threatening illnesses the best quality of life possible
- B. taking care of the whole person"?body, mind, spirit, heart, and soul
- C. no interventions are needed because the client is near death
- D. supporting the needs of the family and client
Correct answer: C
Rationale: The goals of palliative care include choices A, B, and D. Choice C, 'no interventions are needed because the client is near death,' is not part of palliative care. Palliative care involves giving clients with life-threatening illnesses the best quality of life possible, taking care of the whole person"?body, mind, spirit, heart, and soul, and supporting the needs of the family and client. Interventions are crucial in palliative care to ensure the comfort and well-being of the client until the end of life. Therefore, the correct answer is that no interventions are needed because the client is near death.
4. The nurse receives an order to administer phenytoin through the client's J-tube. The order instructs that tube feedings are stopped at least an hour prior to administering the medication and an hour after the medication is administered. Which of the following considerations may be a reason to discuss this order with the physician?
- A. The client has a history of Type II diabetes.
- B. The client is on a continuous tube-feeding regimen.
- C. The client is on fluid restriction.
- D. The pharmacy has provided phenytoin in tablet form.
Correct answer: B
Rationale: For a client on a continuous tube-feeding regimen, stopping tube feedings for two hours to administer this medication may compromise the client's nutritional status. This interruption can lead to inadequate nutrient intake, affecting the client's overall nutritional well-being. The other choices are less relevant in this situation. Type II diabetes does not directly impact the administration of phenytoin through a J-tube. Fluid restriction would not prevent the temporary interruption of tube feedings for medication administration. The form of phenytoin provided by the pharmacy does not impact the need to discuss the order with the physician regarding the client's continuous tube-feeding regimen.
5. During a report from an ER nurse about a client, the nurse identifies a statement that requires additional follow-up. Which of the following statements needs further clarification?
- A. "The client said they have been taking aspirin, but I'm not sure for how long or how much."?
- B. "The client frequently takes antacids, but they have not taken any in the last three days."?
- C. "The client stopped taking ibuprofen after developing gastric ulcers."?
- D. "The client takes Antabuse and has stopped using mouthwash."?
Correct answer: A
Rationale: The correct answer requires further follow-up as the nurse needs to know the duration and dosage of aspirin since it can impact the patient's bleeding risk. Choice B does not require immediate follow-up as not taking antacids for three days is not critical. Choice C indicates a necessary decision made by the client to stop ibuprofen after developing gastric ulcers, hence no immediate follow-up is needed. Choice D provides important information, but the priority is to address the lack of specificity regarding the client's aspirin use, which is crucial for assessing bleeding risk and potential interactions.
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