NGN NCLEX RN NEWEST TEST | ALL QUESTIONS
AND CORRECT ANSWERS WITH RATIONALES |
GRADED A+ | VERIFIED ANSWERS | JUST RELEASED
The nurse cares for a client with an established ascending colostomy.
Which statement made by the client indicates that further teaching is
required? ------CORRECT ANSWER---------------3. "I change the appliance
and bag every other day"
-Peristomal skin irritation may also occur if the ostomy appliance is
removed and changed too frequently. The appliance should be
changed every 5-10 days (Option 3).
The ostomy bag is emptied when one-third full. The client with a
colostomy is encouraged to drink plenty of fluids to prevent
dehydration (the semiliquid consistency of stool from an ascending
colostomy results in increased fluid loss) and decrease intake of gas-
forming foods (beans, onions, broccoli).
The nurse in an ambulatory surgery center triages telephone messages
from clients. Which client should the nurse call back first? ------CORRECT
ANSWER---------------4. Client who underwent placement of an
arteriovenous graft who reports a temperature of 100.9 F (38.3 C)
- Arteriovenous (AV) graft placement involves surgical connection of
an artery and a vein using a synthetic material to graft a hemodialysis
access site. Postoperative infection of an AV graft may cause
thrombosis, graft failure, or systemic infection. Fever in a
postoperative client may indicate infection of the graft site, which
warrants immediate notification of the health care provider (HCP); this
client may require antibiotics and surgical removal of the graft
(Option 4).
The nurse is planning care for a client with bipolar disorder and acute
mania who is being admitted involuntarily after attempting to run across a
,five-lane highway. Which intervention is the priority to include in the care
plan? ------CORRECT ANSWER---------------3. Offer high-calorie snacks the
client can eat while on the move and during tasks
When caring for a client with mania, the nurse should prioritize
physiological needs over psychological or self-fulfillment needs. The
nurse can address imbalanced nutrition in a manic client by providing
high-calorie snacks and finger foods that the client can carry and eat
without having to sit down. Bipolar disorder is characterized by
alternating episodes of depression and mania. Manic clients
demonstrate hyperactivity and distractibility and may refuse to sit still
long enough to drink or eat, placing them at risk for inadequate
nutritional intake.
Click to highlight below the 2 findings that are a safety concern. ------
CORRECT ANSWER---------------1. Clients may forget to take medications
due to cognitive decline, limited hand mobility, and sensory alterations. This
can be problematic because older adults often have various health
conditions and take multiple medications.
Clients can have difficulty remembering familiar faces and the
surrounding environment; they will often become disoriented (eg,
wandering and lost in the neighborhood). This becomes a safety risk
because they are unable to find their way back home and can become
lost for long periods of time.
Becoming more withdrawn indicates the client may be feeling
depressed. The nurse should assess for other symptoms of
depression (eg, hopelessness, loss of pleasure); however, this finding
does not pose an immediate safety concern.
For each characteristic below, click to specify if the characteristic is
consistent with the disease process of Alzheimer disease or delirium. ------
CORRECT ANSWER---------------Alzheimer Disease: irreversible,
hallucinations, speech changes (word-finding difficulties_
,Delirium: acute onset, hallucinations, speech changes
Alzheimer disease is an irreversible, progressive form of dementia.
Speech changes, and memory and social skills slowly decline as the
disease progresses, while hallucinations tend to appear later in the
course of the disease. Delirium is an acute, reversible, alteration in
mental state involving a reduced or fluctuating level of
consciousness, speech changes, and hallucinations.
Complete the following sentence by choosing from the list of options.
The nurse suspects the client's condition is caused by ------CORRECT
ANSWER---------------Neurodegenerative changes in the brain
Alzheimer disease (AD) is caused by neurodegenerative changes in
the brain. As individuals age, some develop insoluble amyloid
plaques in the brain tissue. Amyloid plaques cause an inflammatory
response that leads to cell damage and neuron death in surrounding
areas. In clients with AD, more plaques are apparent, especially in
areas of the brain that are essential for memory and cognitive
function (eg, hippocampus). Ultimately, plaques will involve other
areas of the brain, including the parts responsible for language and
reasoning (eg, cerebral cortex).
In addition to excess amyloid plaques, clients with AD also have
abnormal accumulations of twisted protein (tau) that collect inside
nerve cells and cause neuronal death. The brain will eventually shrink
by the final stage of the disease.
The client is attempting to remove a newly inserted peripheral IV. Which of
the following interventions are appropriate at this time? Select all that
apply. ------CORRECT ANSWER---------------2.Ask the unlicensed assistive
personnel to stay with the client until a sitter is available
3.Play the client's favorite music and look at family photos together
4.Reassure the client that this is a safe environment
, 5.Reinforce the IV insertion site dressing with gauze
Clients with moderate-stage Alzheimer disease (AD) may develop
disruptive behaviors as they become unable to communicate their
needs. When a client with AD is agitated or aggressive, the nurse
should assess for and resolve causes of discomfort, provide
distraction, and reassure the client. The nurse should secure lines,
tubes, and drains and obtain a sitter if needed to maintain safety.
Which of the following statements by the nurse are appropriate? Select all
that apply. ------CORRECT ANSWER---------------1. "Have you considered
joining a caregiver support group?"
3. "Let's talk about services that can help you care for your spouse."
Nurses play an important role in recognizing caregiver distress and
assisting caregivers in accessing services (eg, respite care, adult day
centers, in-home services) that reduce their burden and provide time
for the caregiver's own self-care. Acknowledging the caregiver's
distress and offering services such as a caregiver support group
provide reassurance and offer the caregiver a safe space to discuss
challenges of caregiving with others who can relate and understand
Relating with the client (eg, "I understand what you are going through.
I am here for you") is NOT appropriate or therapeutic because only
the caregiver can understand what they are experiencing.
The nurse is teaching the client's spouse about managing worsening
symptoms during the evening and night. Which of the following statements
by the spouse indicate a correct understanding of the teaching? ------
CORRECT ANSWER---------------1. "I can verbally redirect my spouse when
my spouse refuses care."
2."I should avoid offering my spouse caffeine in the afternoon."
4. "I will keep the lights on and the blinds open during the day."
