Question

A nurse is caring for a client who is scheduled for a bilateral mastectomy. The client is sitting on the side of the bed and appears tearful. The client states, "l will never be the same again." Which of the following would be an appropriate response for the nurse to make?

Answer 1

Correct Answers:

"Are you saying you feel frightened about the results of your upcoming surgery?"

Rationale :

🗣️This response demonstrates therapeutic communication by encouraging the client to verbalize emotions and concerns.

💬Open-ended questions that validate the client's feelings are crucial in emotional care, especially for clients facing body image changes after surgery.

🧠The nurse's role includes supporting emotional expression and clarifying the client’s statements without making assumptions or giving false reassurance.

💗This approach fosters trust and allows further exploration of emotional distress before the surgery.

📌Core Message

Use therapeutic communication to encourage emotional expression and support body image concerns.

Answer 2

Correct Answers:

Jaundice
Circumoral cyanosis
Single palmar crease

Rationale :

🧸Jaundice in a newborn within the first 24 hours may indicate pathologic hyperbilirubinemia, which requires prompt evaluation.

💁‍♂️Circumoral cyanosis suggests a lack of oxygenation and can be an early sign of cardiorespiratory distress.

🖐️A single palmar crease may be associated with chromosomal abnormalities, such as Down syndrome, and needs further assessment.

👉Acrocyanosis and harlequin sign are typically benign and normal in newborns unless persistent.

📌Core Message

Report jaundice, circumoral cyanosis, and a single palmar crease as they may indicate underlying pathology.

Answer 3

Correct Answers:

A high-protein snack

Rationale :

🍽️Clients in a manic state often have high energy levels and poor focus, making it difficult to sit and eat full meals.

💪High-protein, high-calorie snacks provide sustained energy and are easier to consume on the go.

🧠This nutritional approach helps meet metabolic demands without overwhelming the client during heightened activity.

🧃Avoid caffeine and complex meals, as they can increase agitation or be impractical during manic episodes.

📌Core Message

Offer high-protein snacks to meet nutritional needs in clients with mania and reduced meal tolerance.

Answer 4

Correct Answers:

Increase in the number of episodes of dyskinesia

Rationale :

🧠Dyskinesia is a common side effect of long-term levodopa-carbidopa therapy and involves involuntary movements.

💊Reducing the dose may help control these motor side effects while still maintaining the medication's effectiveness.

🧠Clients may initially tolerate the medication well, but over time, the dosage may need adjusting to minimize adverse motor symptoms.

🔄Managing this balance is key to maintaining function and quality of life in clients with Parkinson’s disease.

📌Core Message

Adjust levodopa-carbidopa dosage to control dyskinesia, a long-term side effect in Parkinson’s disease.

Answer 5

Correct Answers:

7-year-old client with a fractured tibia who had an external fixation device applied 10 hours ago.

Rationale :

👶The maternity nurse is most familiar with basic postoperative care and routine monitoring, which makes this client appropriate.

💁‍♂️This case is stable and involves standard surgical recovery, allowing the float nurse to practice safely within their competence.

🚫The other options involve infectious diseases (chickenpox), neurosurgical procedures, or complex recovery, requiring pediatric-specific skills.

🧠Safe assignment ensures client safety and protects the nurse's scope of practice.

📌Core Message

Assign stable and familiar cases to float nurses to ensure safe and competent care.

Answer 6

Correct Answers:

Who is menstruating.

Rationale :

🩸Menstruation is not a contraindication for fibrinolytic therapy in clients with myocardial infarction.

🚫Uncontrolled hypertension and a history of cerebral aneurysm increase the risk of life-threatening hemorrhage, making them contraindications.

💊Clients on warfarin already have an altered coagulation state, increasing the risk of bleeding with fibrinolytics.

🧠The client who is menstruating remains a safe candidate for this therapy despite the presence of mild bleeding.

📌Core Message

Fibrinolytics are safe in menstruating clients but contraindicated in high bleeding-risk conditions.

Answer 7

Correct Answers:

Had a total hip arthroplasty 24 hours ago.

Rationale :

🛏️A client recovering from surgery 24 hours ago is generally hemodynamically stable and receiving postoperative care, which oncology nurses are familiar with.

🧑‍⚕️Clients who are preoperative or had surgery only a few hours ago may have higher acuity or require emergency interventions.

🧠Assigning based on the nurse’s experience ensures client safety and appropriate clinical decision-making.

🩺The oncology nurse’s familiarity with post-op assessments makes this client suitable.

📌Core Message

Match float nurses to stable post-op clients within their clinical experience.

Answer 8

Correct Answers:

Initiate diaphragmatic breathing exercises.

Rationale :

💁‍♂️Panic attacks often result in hyperventilation, leading to symptoms like dizziness and chest tightness.

🧘‍♀️Diaphragmatic breathing helps regulate CO₂ levels, reduce hyperventilation, and ease panic symptoms.

🧠This non-pharmacologic intervention can be immediately implemented and empowers the client to self-manage symptoms.

💊Medication may be used if necessary, but calming techniques are a safe and effective first-line strategy.

📌Core Message

Use diaphragmatic breathing first to manage panic attack symptoms and reduce hyperventilation.

Answer 9

Correct Answers:

"l will shake the inhaler before using it."

Rationale :

🚫Dry powder inhalers (DPIs) should not be shaken, as they do not contain a propellant like metered-dose inhalers (MDIs).

🧠Shaking a DPI can cause medication loss or improper dosing.

💨Proper DPI use includes deep, rapid inhalation and holding breath to allow absorption.

📚The nurse should correct this misunderstanding to ensure effective medication delivery.

📌Core Message

Avoid shaking dry powder inhalers, as it interferes with correct medication delivery.

Answer 10

Correct Answers:

Identify potential self-harm or harm to others.

Rationale :

🧠The priority during a manic episode is ensuring the client’s safety, as impulsivity and poor judgment may lead to harmful behavior.

🚨Assessing for risk of self-injury or aggression allows for immediate interventions to prevent incidents.

💊Medication and routine planning are important but are secondary to safety assessment.

🛡️Once the risk is identified or ruled out, the nurse can then proceed with the broader plan of care.

📌Core Message

During manic episodes, first assess for risk of harm to ensure client and staff safety.

NCLEX RN-Readiness Assessment Test-3

No.

1 :
A nurse is caring for a client who is scheduled for a bilateral mastectomy. The client is sitting on the side of the bed and appears tearful. The client states, "l will never be the same again." Which of the following would be an appropriate response for the nurse to make?

2 :
A nurse is assessing a newborn. Which of the following findings should be reported to the primary health care provider? Select all that apply

3 :
A client diagnosed with bipolar I disorder is exhibiting heightened energy levels, rapid speech, and decreased need for sleep.
Which of the following dietary options should the nurse prioritize?

4 :
A nurse is caring for a client with Parkinson disease who is receiving levodopa-carbidopa. The nurse notes that the primary health care provider has prescribed a reduced dose of the medication. The nurse should recognize that the reduced dose is to manage the:

5 :
A charge nurse is preparing the client care assignment for a nurse from a maternity unit who is temporarily assigned to a pediatric unit. It would be most appropriate for the charge nurse to assign the maternity nurse to a:

6 :
A nurse in the emergency department (ED) is caring for assigned female clients who have had a myocardial infarction. The nurse should recognize that fibrinolytic therapy would be most appropriate for the client:

7 :
A nurse from the oncology unit has been temporarily assigned to the surgical unit. It would be most appropriate to assign the oncology nurse to a client who:

8 :
A client with a panic attack is exhibiting tachypnea and tachycardia. Which of the following interventions should the nurse prioritize?

9 :
A nurse has taught a client with asthma about using a dry powder inhaler. Which of the following statements by the client would require follow-up?

10 :
A nurse is caring for a hospitalized client diagnosed with bipolar disorder experiencing an acute manic episode. Which of the following interventions should the nurse prioritize?

NCLEX RN-Readiness Assessment Test-3

No.

1 : A nurse is caring for a client who is scheduled for a bilateral mastectomy. The client is sitting on the side of the bed and appears tearful. The client states, "l will never be the same again." Which of the following would be an appropriate response for the nurse to make?

2 : A nurse is assessing a newborn. Which of the following findings should be reported to the primary health care provider? Select all that apply

3 : A client diagnosed with bipolar I disorder is exhibiting heightened energy levels, rapid speech, and decreased need for sleep.Which of the following dietary options should the nurse prioritize?

4 : A nurse is caring for a client with Parkinson disease who is receiving levodopa-carbidopa. The nurse notes that the primary health care provider has prescribed a reduced dose of the medication. The nurse should recognize that the reduced dose is to manage the:

5 : A charge nurse is preparing the client care assignment for a nurse from a maternity unit who is temporarily assigned to a pediatric unit. It would be most appropriate for the charge nurse to assign the maternity nurse to a:

6 : A nurse in the emergency department (ED) is caring for assigned female clients who have had a myocardial infarction. The nurse should recognize that fibrinolytic therapy would be most appropriate for the client:

7 : A nurse from the oncology unit has been temporarily assigned to the surgical unit. It would be most appropriate to assign the oncology nurse to a client who:

8 : A client with a panic attack is exhibiting tachypnea and tachycardia. Which of the following interventions should the nurse prioritize?

9 : A nurse has taught a client with asthma about using a dry powder inhaler. Which of the following statements by the client would require follow-up?

10 : A nurse is caring for a hospitalized client diagnosed with bipolar disorder experiencing an acute manic episode. Which of the following interventions should the nurse prioritize?

1 :
A nurse is caring for a client who is scheduled for a bilateral mastectomy. The client is sitting on the side of the bed and appears tearful. The client states, "l will never be the same again." Which of the following would be an appropriate response for the nurse to make?

2 :
A nurse is assessing a newborn. Which of the following findings should be reported to the primary health care provider? Select all that apply

3 :
A client diagnosed with bipolar I disorder is exhibiting heightened energy levels, rapid speech, and decreased need for sleep.
Which of the following dietary options should the nurse prioritize?

4 :
A nurse is caring for a client with Parkinson disease who is receiving levodopa-carbidopa. The nurse notes that the primary health care provider has prescribed a reduced dose of the medication. The nurse should recognize that the reduced dose is to manage the:

5 :
A charge nurse is preparing the client care assignment for a nurse from a maternity unit who is temporarily assigned to a pediatric unit. It would be most appropriate for the charge nurse to assign the maternity nurse to a:

6 :
A nurse in the emergency department (ED) is caring for assigned female clients who have had a myocardial infarction. The nurse should recognize that fibrinolytic therapy would be most appropriate for the client:

7 :
A nurse from the oncology unit has been temporarily assigned to the surgical unit. It would be most appropriate to assign the oncology nurse to a client who:

8 :
A client with a panic attack is exhibiting tachypnea and tachycardia. Which of the following interventions should the nurse prioritize?

9 :
A nurse has taught a client with asthma about using a dry powder inhaler. Which of the following statements by the client would require follow-up?

10 :
A nurse is caring for a hospitalized client diagnosed with bipolar disorder experiencing an acute manic episode. Which of the following interventions should the nurse prioritize?