NCLEX RN LATEST EXAM FALL-WINTER 2024/2025
VERIFIED QUESTIONS AND ANSWERS WITH
RATIONALE GRADED A+
Nurse does ED triage. unemancipated minor requests treatment. registration clerk
states they need guardian's consent for treatment. which is the nurse's next action?
- triage after guardian consent obtained
- ask minor about medical reason for seeking treatment
- request HCP perform medical screening exam
- notify nursing supervisor
ask the minor about the medical reason for seeking treatment (wrong, picked d)
rationale: unemancipated minors may consent to medical treatment if they have
specific medical conditions- pregnancy/STI/substance abuse/mental health, not
appropriate for nurse to notify nursing supervisor before assessing situation and
determining whether consent is required
Nurse makes med surg unit assignments. LPN assigned to client with localized
herpes zoster. LPN tells nurse "i have never had chickenpox" which response by
nurse is most appropriate?
- use standard precautions when caring for this pt
,NCLEX RN LATEST EXAM FALL-WINTER 2024/2025
- you will be fine, airborne precautions needed
- your client assignment will be changed
- why are you concerned about providing care for this pt?
your client assignment will be changed (wrong, picked a)
rationale: localized herpes zoster is shingles, if you care for pt with herpes zoster
you could get chickenpox from them
caring for pregnant and postpartum pts. which client does the nurse see 1st?
- 6wks gestation, LPN can't get fetal heart tones with doptone
- 5 days postpartum, bright red bloody discharge
- 22 wks gestation, feels fetal movement 4times per hour
- 2 days postpartum, has urinary incontinence
5 days postpartum pt reporting bright red, blood discharge (correct)
rationale: bloody discharge (rubra lochia) should only last 1-3 days - need to
monitor amount and color in addition to vital signs, fetal heart tones can't be heard
until 8-12 wks, less than 3 fetal movements in 1 hour could indicate fetal issue,
urinary incontinence is normal during postpartum- teach kegels
pt has CLL is scheduled for bone marrow aspiration and biopsy. pt says, "i'm
frightened i haven't had this test before and i don't know what to expect" which
statements will nruse include when responding to pt's concerns? SATA
,NCLEX RN LATEST EXAM FALL-WINTER 2024/2025
- we will move you to operating room where test is always performed
- bone in the front of the chest will be used for biopsy
- a tight pressure dressing will be placed over test site after procedure
- you will not feel any discomfort as the local anesthetic is injected
- risk of bleeding present, so will monitor test site frequently
tight pressure dressing placed over testing site after procedure & there is a risk of
bleeding, so we will monitor the test site frequently
rationale: bone marrow aspiration/biopsy can be done in pt room or a treatment
room not OR, don't use sternum for biopsy, pressure dressing helps with bleeding,
sting/discomfort during biopsy, can cause bleeding
nurse speaks with pt and spouse who have been undergoing family counseling. pt's
spouse states " you never take any responsibility for the messes you always cause"
which response by nurse is best?
- why do you say that?
- blaming is not effective
- let's focus only on positives
- when is the last time you two had a vacation
blaming isn't effective (wrong, picked c)
rationale: don't ask why, telling them blaming isn't effective helps keep focus on
both people, "only" isn't a good word
, NCLEX RN LATEST EXAM FALL-WINTER 2024/2025
pt diagnosed with malnutrition has continuous enteral feedings through newly
placed gastrostomy tube. which actions will nurse include in plan of care? SATA
- cover insertion site with adhesive bandage
- add 8 hours of feeding to bag at a time
- rotate gastrostomy tube 360 degrees once daily
- auscultate for whoosh of air through gastrostomy tube
- check for slight in and out movement of gastrostomy tube
rotate gastrostomy tube 360 degrees once daily & check for slight in and out
movement of gastrostomy tube
rationale: insertion site should be covered with sterile bandage to reduce infection
risk until stoma is healed, only 4 hours of enteral feeding added to bag at a time to
reduce bacterial contamination, rotate 360 degrees daily to reduce risk of skin
irritation and breakdown, don't insert air for gastrostomy rube assessment, slight
in/out indicates tube isn't embedded in wall of stomach
nurse asses pt for potential spousal abuse. nurse is most concerned if pt makes
which statement?
- it's my fault because I push my spouses buttons
- my spouse and i often disagree on many things
- we have talked about divorce multiple time
- i used to be so happy, but now I am not
it's my fault because i push my spouse's buttons (correct)
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