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NCLEX-PN Package Deal Newest 2025 featuring 500 comprehensive practice questions and verified answers covering all major nursing categories, including pharmacology, health promotion, physiological integrity, and coordinated care.
A client on hospice home care is taking sips of water, but refusing food. Family members appear distressed and insists the personal care worker force feed the client. What is the priority nursing action?
- explain to the family that is the normal physiological
- explore the families, thoughts and concerns about the clients
- recommend a feeding tube
- tell the family that force feeding the client could cause the
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response to dying
refusal food
client to choke on the food - ANSWER-B Rationale; It's common for family members to become distressed when a terminally ill loved one refuses food. The nurse should explore their fears and concerns and help them identify other ways to express how they care.
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The nurse is performing rounding on clients in restraints. Which situation would require immediate intervention by the nurse?
- client in a belt restraint in the semi Fowler position
- client in mitten restraints in the side lying position
- client in soft wrist restraints in the supine position
- client in vest restraint in the high Fowlers position -
ANSWER-C
Rationale; Restrained clients are at risk for aspiration when supine. They cannot safely swallow expel, secretions or emesis.They should be placed in side lying, semi Fowler, or high fowler position.
The nurse is preparing to administer eardrops to an adult client.It would require follow up if the nurse.
- instills the eardrops at room temp
- instills the ear drops by placing the dropper into the ear canal
- pulls the pinna of the clients ear up and back before
- place is a cotton ball loosely in the outer, most auditory canal
installation
after installation - ANSWER-B Rationale; The nurse should hold the dropper 1/2 inch or 1 cm above the ear canal to avoid damaging the ear with the dropper. 2 / 4
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Eardrops should be warm, a cotton ball should be placed, pin a should be pulled back
The nurse is preparing to irrigate the wound of a seven year old client who sustained a laceration while on a playground. Which of the following action should the nurse take? SATA
- administer, he prescribed analgesic 30 minutes before
- cleanse the wound from the most contaminated to the least
- obtain a 10 mL syringe and a 27 gauge needle
- review the clients vaccination record
- use continuous pressure to flush the wound repeat until
irrigating the
contaminated area
drainage is clear - ANSWER-A, D, E Rationale; Administer analgesic, 30 to 60 minutes before, fill 30 to 60 mL sterile irrigation syringe, attach 18 or 19 gauge needle to syringe, use continuous pressure, dry surrounding wound area to prevent skin breakdown, clean from the least to the most contaminated area
The nurse prepares to administer a cleansing enema to a client with constipation. Which nursing interventions are appropriate?
SATA 3 / 4
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- apply water-based lubricant to the end of a tube
- assist the client into left lateral position
- encouraged client to retain the enema for as long as possible
- keep the animal solution refrigerated
- stop the infusion if the client reports abdominal cramping -
ANSWER-A, B, C, E
Rationale; Place client and left lateral with right knee flexed, lubricate, and insert animal tube into rectum with the tip directed towards the umbilicus, slow rate of administration is cramping.Enemas should be administered at room, temp, or warm.
The nurse is caring for a six month old client with a new tracheostomy. Which of the following findings would indicate that the clients airway require suctioning? SATA
- audible gurgling
- heart rate of 110/min
- increased irritability
- oxygen saturation of 88%
- respiratory rate of 30/min - ANSWER-A, C, D
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Rationale; A heart rate of 110 and a respiratory rate of 30 are within normal limits for a six month old client and do not indicate respiratory distress