2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Deta, Exams of Nursing

Download 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Deta and more Exams Nursing in PDF only on Docsity! 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success A toddler with vomiting, diarrhea, and dehydration is being seen at an acute care center. During the admission interview, what question will the nurse ask the parents to elicit the most useful information? a. "Watching your child vomiting and in discomfort must have been scary." b. "This started yesterday, correct?" c. "Has this child has had anything to drink?" d. Could you tell me the color and approximate amount of the vomiting? - CORRECT ANSWERS d. Using a clarifying question or comment allows the nurse to gain an understanding of the parents' observations, avoiding misunderstandings that could lead to an inappropriate nursing diagnosis. A reflective question technique involves repeating what the person has said or describes the person's feelings. Assertive questions are direct, demonstrating the ability to stand up for self or others, using open and honest communication. Open-ended questions encourage free verbalization and expression of what the parents believe to be true. A nurse enters a patient's room and examines the patient's intravenous (IV) fluids and cardiac monitor. When asked, "who are you?", which response by the nurse is most appropriate? a. "I'm just the IV therapist checking your IV." b. "I've been transferred to this division and will be caring for you." c. "I'm sorry, my name is John Smith and I am your nurse." d. "I am John Smith, your nurse, and I'll be caring for you until 11 PM." - CORRECT ANSWERS d. The nurse should identify themselves, ensure the patient knows what will be happening, and the duration of their relationship. A nurse enters the room of a patient with cancer. The patient is crying and states, "I feel so alone." How will the nurse best communicate a therapeutic response? a. The nurse stands at the patient's bedside and states, "I understand how you feel. My mother said the same thing when she was ill." b. The nurse places a hand on the patient's arm and states, "You feel so alone." c. The nurse stands in the patient's room and asks, "Why do you feel so alone? Your wife has been here every day." d. The nurse holds the patient's hand and asks, "Tell me what feeling so alone is like for you?" - CORRECT ANSWERS d. The use of touch conveys acceptance, and the implementation of an open-ended question allows the patient time to verbalize freely. 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success The charge nurse overhears an AP yelling loudly to a patient who is hard of hearing, while transferring them from the bed to a chair. Upon entering the room, which response by the charge nurse is most appropriate? a. "Please speak more quietly so you don't disturb the other patients." b. "Let me help you with your transfer technique." c. "When you are finished, be sure to apologize for shouting." d. "When your patient is safe and comfortable, meet me at the desk." - CORRECT ANSWERS d. The charge nurse should direct the AP to see to the patient's safety, then address any concerns privately. The nurse then can discuss appropriate use of therapeutic communication. A public health nurse is leaving the home of a young mother who has an infant with special needs. The neighbor states, "How is she doing, since the baby's father is no help?" What is the nurse's best response? a. "New mothers need support." b. "The lack of a father is difficult." c. "How are you today?" d. "It is a very sad situation." - CORRECT ANSWERS a. The nurse must maintain confidentiality when providing care. The statement "New mothers need support" is a general statement that all new parents need help. The statement is not judgmental of the family's roles. "How are you today?" is dismissive of the neighbor's question. A primary nurse is preparing a discharge plan for a patient who has been hospitalized following a double mastectomy. Which statement is most appropriate for the nurse to use in the termination phase of the therapeutic relationship? a. "Let's review the progress you've made in meeting your goals." b. "I'd like to review your medication schedule with you." c. "I need to document today's teaching session in the electronic health record." d. "Should we include your family in today's session?" - CORRECT ANSWERS a. The termination phase occurs when the conclusion of the initial agreement is acknowledged. Discharge planning correlates with the termination phase of a therapeutic relationship and the progress toward the patient's goals are reviewed. 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success Pulse oximetry 96% a. Admitted with peptic ulcer and bleeding disorder b. Found vomiting in bathroom c. Anti-ulcer medication recommendation d. Vital signs, oxygen saturation, bright red emesis - CORRECT ANSWERS d. The SBAR method is used to improve hand-off communication. SBAR, which stands for Situation, Background, Assessment, and Recommendations, provides a clear, structured, and easy to use framework. Vital signs, oxygen saturation, and the presence of emesis and its color are assessments. The nurse preceptor and a new graduate nurse on the surgical unit are performing preoperative assessments on a group of patients. What statement by the graduate nurse requires the preceptor to intervene? a. "I am sure everything will be fine; you have nothing to worry about." b. "When you return from surgery, you'll need to cough and deep breathe." c. "Many people on this unit have had that procedure with good success." d. "You seem fearful, can I answer any questions about the procedure?" - CORRECT ANSWERS a. Telling a patient that everything will be fine is a cliché. This statement gives false assurance and may give the patient the impression that the nurse is dismissive of a patient's concerns or condition. A patient states, "I have been experiencing complications of diabetes." What question will the nurse use to elicit additional information? a. "Do you take two injections of insulin to prevent complications?" b. "Are you using diet and exercise to help regulate your blood sugar?" c. "Have you been experiencing the complications of neuropathy?" d. "Can you tell me about the complications you've experienced?" - CORRECT ANSWERS d. Requesting information regarding the patient's specific complications of diabetes will guide the nurse to further questioning and related assessments. During an interaction with a patient diagnosed with epilepsy, a nurse notes that the patient is silent after hearing the plan of care. How does the nurse best respond? Select all that apply. a. Fill the silence with lighter conversation directed at the patient. 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success b. Use the time to perform the care that is needed uninterrupted. c. Discuss the silence with the patient to ascertain its meaning. d. Allow the patient time to think and explore inner thoughts. e. Determine if the patient's culture requires pauses between conversation. f. Arrange for a counselor to help the patient cope with emotional issues. - CORRECT ANSWERS c, d, e. Appropriate use of silence allows the patient to initiate or to continue speaking; the nurse can reflect on what has been shared while observing the patient without having to concentrate simultaneously on conversation. In due time, the nurse might discuss the meaning of silence with the patient. The nurse considers whether the patient's culture may require longer pauses between verbal communication. Fear of silence sometimes leads to excessive talking by the nurse, displacing focus from the patient. The nurse should not assume silence requires a consult with a counselor. 1. A nurse caring for older adults in a provider's office researches aging theories to help determine why some people age more rapidly than others. Which statements describe the immunity theory of the aging process? Select all that apply. a. Immunosenescence likely promotes the increase in infections in the older adult. b. Free radicals have adverse effects on adjacent molecules. c. Decreases in size and function of the thymus result in more infections. d. Nutrition likely plays an important role in maintaining the immune response. e. Lifespan depends to a great extent on genetic factors. f. Organisms wear out from increased metabolic functioning. - CORRECT ANSWERS a, c, d. The immunity theory of aging focuses on the functions of the immune system and states that the immune response declines steadily after younger adulthood as the thymus loses size and function, resulting in more infections. Vitamin supplements (such as vitamin E) may improve immune function. The cross-linkage theory proposed that a chemical reaction produces damage to the DNA and cell death. The free radical theory states that free radicals —molecules with separated high-energy electrons—formed during cellular metabolism can have adverse effects on adjacent molecules. The genetic theory of aging holds that lifespan depends to a great extent on genetic factors. According to the wear-and-tear theory, organisms wear out from increased metabolic functioning, and cells become exhausted from continual energy depletion from adapting to stressors. 1. A nursing student caring for older adults in a skilled nursing facility is completing an assignment identifying physical changes that are part of normal aging. What changes will the student include in this assignment? Select all that apply. a. Fatty tissue is redistributed. 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success b. Skin is drier and wrinkles appear. c. Cardiac output increases. d. Muscle mass increases. e. Hormone production increases. f. Visual and hearing acuity diminishes. - CORRECT ANSWERS a, b, f. Physical changes occurring with aging include these: fatty tissue is redistributed, the skin is drier and wrinkles appear, and visual and hearing acuity diminishes. Cardiac output decreases, muscle mass decreases (sarcopenia), and hormone production decreases, causing menopause or andropause. 1. A nurse researcher interviews adults to validate Erikson's theory that middle-aged adults who do not achieve their developmental tasks may be in the stage of stagnation. Which patient statement will the nurse correlate to this theory? a. "I am helping my parents move into an assisted-living facility." b. "I spend all of my time going to the doctor to be sure I am not sick." c. "I have enough money to help my son and his wife when they need it." d. "I earned this gray hair and I like it!" - CORRECT ANSWERS b. According to Erikson (1963), the middle adult is in a period of generativity versus stagnation. The tasks are to establish and guide the next generation, accept middle-age changes, adjust to the needs of aging parents, and reevaluate goals and accomplishments. Middle adults who do not reach generativity tend to become overly concerned about their own physical and emotional health needs. 1. A nurse providing health services for a community setting for people age 55 years and older considers health problems for these residents. Which of the following problems is most appropriate for many middle-aged adults? a. Adequate nutrition b. Mental health problems c. Abuse d. Caregiver role strain - CORRECT ANSWERS d. Many middle-aged adults help care for aging parents and have concerns about their own health and ability to continue to care for an older family member. Caregivers often face 24-hour care responsibilities for extended periods of time, which creates physical and emotional problems for the caregiver. Nutritional issues are more common in the childhood years and possibly in older adults. Mental health issues and abuse can occur in multiple age groups. 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success f. S—Skin breakdown - CORRECT ANSWERS b, d, f. The SPICES acronym is used to identify common problems in older adults and stands for: S—Sleep disorders P—Problems with eating or feeding I—Incontinence C—Confusion E—Evidence of falls S—Skin breakdown 1. The nurse in a long-term care facility states in report that an older adult resident is quite frail. The oncoming caregiver prioritizes prevention of what problem? a. Confusion b. Falls c. Delirium d. Dementia - CORRECT ANSWERS b. Fear of falling, indicators of frailty, and personality traits of high neuroticism and low conscientiousness contribute to falls in older adults. Falling once doubles the chance of the older adult falling again. 1. A patient is admitted to the acute care medical center with change in mental status, dehydration, and electrolyte imbalances. Which of these reflects a reversible cause of the changes in mental status? a. Alzheimer's disease b. Delirium c. Dementia d. Delirium superimposed on dementia - CORRECT ANSWERS b. Delirium, an acute syndrome of brain failure, can last from hours to weeks, has a specific cause, and resolves with treatment of the identified underlying cause. Symptoms of delirium include deficits in attention, awareness, and cognition. Dementia refers to various organic disorders affecting cognitive function that are progressive and irreversible. The nurse manager and nurses in an acute care hospital are participating in a safety huddle to identify patients at risk for falling. Which patients will the nurses determine require follow-up? Select all that apply. a. Age >50 years b. History of falling c. Taking antibiotics d. Presence of postural hypotension e. Nausea from chemotherapy 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success f. Transferred from long-term care - CORRECT ANSWERS b, d, f. Risk factors for falls include age >65 years, documented history of falls, postural hypotension which can cause dizziness, and unfamiliar environment. A medication regimen that includes diuretics creating urinary urgency and tranquilizers, sedatives, hypnotics, or analgesics causing altered mental status and impaired judgment are also risks. Chemotherapy or antibiotics are not included as factors leading to falls. A school nurse is teaching parents about home and fire safety. What information will be included in the teaching plan? Select all that apply. a. Sixty percent of U.S. fire deaths occur in the home. b. Most fatal fires occur when people are cooking. c. Most people who die in fires die of smoke inhalation. d. Fire-related injury and death have declined due to the availability and use of smoke alarms. e. Fires are more likely to occur in homes without electricity or gas. f. Fires are less likely to spread if bedroom doors are kept open when sleeping. - CORRECT ANSWERS c, d, e. Eighty percent of fire deaths in the United States occur in the home. Most fatal home fires occur while people are sleeping, and most deaths result from smoke inhalation rather than burns. The widespread availability and use of home smoke alarms is considered the primary reason for the decline in fire-related injury and death. People with limited financial resources may use space or kerosene heaters, wood stoves, or a fireplace as the sole source of heat if utilities are turned off. Bedroom doors should be kept closed when sleeping and monitors used to listen for children. A community health nurse is providing education on child safety. Who does the nurse identify as at highest risk for choking and suffocation? a. A toddler playing with his older brother's wooden blocks b. A 4-year-old eating yogurt and strawberries for lunch c. An infant sleeping in the prone position d. A 3-year-old drinking a glass of juice - CORRECT ANSWERS c. Infants should be placed on their backs to sleep. A young child may place small or loose parts in the mouth. Anything that will fit through the average toilet paper roll is not safe for a toddler. A 3-year-old and a 4-year-old drinking juice and eating yogurt are developmentally appropriate. While discussing home safety with the nurse, a patient admits that they smoke a cigarette in bed before falling asleep at night. Which health problem is the priority for this patient? 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success a. Impaired gas exchange: etiology, cigarette smoking b. Acute anxiety: etiology, inability to stop smoking c. Nonadherence: etiology, nonadherence to recommendation to stop smoking d. Knowledge deficiency: etiology, risk for burn and suffocation in a house fire - CORRECT ANSWERS c. Because the patient is not aware or denies that smoking in bed poses a danger for fire and toxic fumes, education about the risk for burns and suffocation is needed. The other three nursing diagnoses are correctly stated but are not a priority in this situation. A nurse working in a pediatrician's office receives calls from parents whose children have ingested a toxic substance from under the sink. How will the nurse advise the parents? a. Administer activated charcoal in tablet form and take child to the ED. b. Administer syrup of ipecac and take child to the ED. c. Bring the child in to the primary care provider for gastric lavage. d. Call the PCC immediately before attempting any home remedy. - CORRECT ANSWERS d. The nurse tells the parents to call the PCC immediately, before attempting a home remedy. Parents may be instructed to bring the child to an emergency facility for immediate treatment. Activated charcoal is not appropriate to use at home but under medical supervision, after the risks and benefits have been assessed. Syrup of ipecac is no longer recommended because vomiting may exacerbate the hazard as it vomited up. Gastric lavage is no longer prescribed routinely for the treatment of ingestion of a toxic substance because it may propel the poison into the small intestine, where absorption will occur. The amount of toxin removed by gastric lavage is relatively small. A nurse is teaching parents in a parenting class about the use of car seats and restraints for infants and children. What should be the focus of this education? a. Booster seats should be used for children until they are 4 9″ tall and weigh between 80 ′ and 100 lb. b. Most U.S. states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle. c. Infants and toddlers up to age 2 years (or the maximum height and weight for the seat) should be in a front-facing safety seat. d. Children age older than 6 years may be restrained using a car seat belt in the back seat. - CORRECT ANSWERS a. Booster seats should be used for children until they are 4 9″ tall and ′ weigh between 80 and 100 lb. All 50 U.S. states mandate the use of infant car seats and carriers when transporting a child in a motor vehicle. Infants and toddlers up to age 2 years (or up to the maximum height and weight for the seat) should be in a rear-facing safety seat. Many children older than age 6 years should still be in a booster seat. 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success Identifying the patient's door with their photo and a balloon may resolve the issue without restraints. Using the geriatric chair and sheets are forms of physical restraint. Leaving the bed in the high position is a safety risk and would likely result in a fall. A nurse has exhausted every effort to keep a confused, postoperative patient safe and in bed. Following The Joint Commission guidelines for use of restraints, which nursing action reflects safe practice? a. Positioning the patient in the supine position prior to applying wrist restraints b. Ensuring that two fingers can be inserted between the restraint and patient's wrist c. Applying a cloth restraint to the left hand of the patient with an IV catheter in the right wrist d. Tying an elbow restraint to the raised side rail of the patient's bed - CORRECT ANSWERS b. The nurse should be able to place two fingers between the restraint and a patient's wrist or ankle. Restraining the patient in a supine position increases the risk of aspiration. Due to the IV in the right wrist, alternative forms of restraints should be tried, such as a cloth mitt or an elbow restraint. Securing the restraint to a side rail may injure the patient when the side rail is lowered. During the admission process, a nurse orients an older adult to their hospital room. What is the current safety priority? a. Explaining how to use the telephone b. Introducing the patient to their roommate c. Reviewing the hospital policy on visiting hours d. Demonstrating how to operate the call bell - CORRECT ANSWERS d. Teaching the patient to use the call bell is a safety priority; knowing how to use the phone, meeting the roommate, and knowledge of visiting hours will not necessarily prevent an accidental injury. A nurse works in a facility stating they support a culture of safety. What will the nurse expect to find operationalized in this culture? Select all that apply. a. Support for reporting errors and near misses without blame b. Nurses being the employees responsible for safety in the organization c. Commitment of resources to address actual/potential safety issues d. Emphasis placed on individuals, their departments, and resources e. Promotion of teamwork and collaboration throughout the organization 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success f. Administrators' and managers' commitment to safe operations - CORRECT ANSWERS a, c, e, f. The key features of a culture of safety include: (1) acknowledging the high-risk nature of health care and the commitment to safe operations, (2) maintaining a blame-free environment where reporting is protected and expected, (3) promoting teamwork and collaboration to prevent and seek solutions to patient safety issues, and (4) valuing safety as a focus in all health care facilities, the home, workplace, and community. A school nurse is teaching about adolescent safety with students entering high school. What will the nurse include in the discussion about the major causes of death in this group? Select all that apply. a. Choking b. Diving accidents c. Car accidents d. Suicide e. Intimate partner violence f. Cigarette smoking - CORRECT ANSWERS c, d. Car accidents and suicide are common causes of death in adolescents. Choking is more typical in children younger than age 3 years. While diving accidents can occur in adolescents due to poor judgment, this is not as common. Intimate partner violence is more common in adults. Smoking, while ill advised, takes many years or decades to become a cause of death. A nurse on a postpartum unit is teaching new parents about newborn safety and sleep patterns. Which comment from a parent indicates further teaching is required? a. "I can expect my newborn to sleep an average of 16 to 24 hours a day." b. "Eye movements or groans during my baby's sleep is an emergency." c. "It is essential that I place my infant on their back to sleep." d. "I will not place pillows or blankets in the crib to prevent suffocation." - CORRECT ANSWERS b. Eye movements, groaning, grimacing, and moving are normal activities at this age; no emergency exists. Newborns sleep an average of 16 to 24 hours a day. Infants should be placed on their backs for the first year to prevent SIDS. Parents should be cautioned about placing pillows, crib bumpers, quilts, stuffed animals, and other items in the crib as they pose a suffocation risk. A nurse observes involuntary muscle jerking in a sleeping patient. What action will the nurse take next? a. No action is necessary; this is normal in stage 1 sleep. 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success b. Report the neurologic deficit to the health care provider. c. Lower the temperature in the patient's room. d. Awaken the patient, as this is an indication of night terrors. - CORRECT ANSWERS a. Involuntary muscle jerking occurs in stage I NREM sleep and is a normal finding. No further actions are needed for this patient. A nurse working the night shift is watching the monitors on a telemetry unit and observes a slight increase in a patient's vital signs during sleep. Which of these points will the nurse correlate to changes in vital signs? Select all that apply. a. They are aware of his surroundings at this point. b. They are in delta sleep at this time. c. It would be most difficult to awaken them at this time. d. This is most likely an NREM stage. e. This stage constitutes around 20% to 25% of total sleep. f. The muscles are relaxed in this stage. - CORRECT ANSWERS c, e. This scenario describes REM sleep. During REM sleep, it is difficult to arouse a person, and the vital signs increase. REM sleep constitutes about 20% to 25% of sleep. In stage I NREM sleep, the person is somewhat aware of surroundings. In stage IV NREM sleep (delta sleep), the muscles are relaxed, whereas small muscle twitching may occur in REM sleep. A nurse working in a sleep lab observes the developmental factors that may affect sleep. Which statements accurately describe these variations? Select all that apply. a. REM sleep constitutes much of the sleep cycle of a preschool child. b. By age 8 years, most children no longer take naps. c. Sleep needs usually decrease when physical growth peaks. d. Many adolescents do not get enough sleep. e. Total sleep decreases in adults with a decrease in stage IV sleep. f. Sleep is less sound in older adults, and stage IV sleep may be absent. - CORRECT ANSWERS d, e, f. Many adolescents do not get enough sleep due to the demands of school, activities, and part-time employment. Total sleep time decreases during adult years, with a decrease in stage IV sleep. Sleep is less sound in older adults, and stage IV sleep is absent or considerably decreased. REM sleep constitutes much of the sleep cycle of a young infant, and by the age of 5 years, most children no longer nap. Sleep needs usually increase when physical growth peaks. 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success d. Daily measurement of fluid intake and output e. Presence of anxiety or worries affecting sleep f. Morning and evening blood pressure readings - CORRECT ANSWERS a, b, e. A sleep diary includes mental and physical activities performed during the day and the presence of any anxiety or worries the patient may be experiencing that affect sleep. A record of fluid intake and output, body temperature, and blood pressure is typically kept in the graphic record. A nurse in a rehabilitation facility develops a plan to help promote patients' sleep. What interventions will the nurse include in the plan? Select all that apply a. Maintain a consistent bedtime and time to awaken. b. Drink two or three glasses of water at bedtime. c. Have a large snack at bedtime. d. Take a sedative-hypnotic every night at bedtime. - CORRECT ANSWERS a. Keeping a consistent bedtime and awakening schedule, even when up late, helps promote sleep. Drinking two or three glasses of water at bedtime will probably cause the patient to awaken during the night to void. A large snack may be uncomfortable right before bedtime; instead, a small protein and carbohydrate snack is recommended. Taking a sedative-hypnotic every night disturbs REM and NREM sleep, and sedatives also lose their effectiveness quickly. A nurse is caring for an older adult who is having trouble falling asleep at night. What nursing interventions are appropriate for this patient? Select all that apply. a. Assess the patient for depression. b. Discourage napping during the day. c. Decrease fluids during the evening. d. Administer diuretics in the morning. e. Encourage the patient to engage in some type of physical activity. f. Assess medication for side effects of sleep pattern disturbances. - CORRECT ANSWERS a, b, d, e, f. For patients who are having trouble initiating sleep, the nurse should arrange for assessment for depression and treatment, discourage napping, promote activity, and assess medications for sleep disturbance side effects. Limiting fluids and administering diuretics in the morning are appropriate interventions. A nursing student is caring for an older adult with arthritis who states she did not sleep well and was "up all night to use the bathroom." To help promote sleep, the student plans to discuss re-timing which medication with the primary nurse? 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success a. Furosemide (diuretic) 10:00 AM, 10:00 PM b. Melatonin 9:00 PM c. Acetaminophen 10:00 AM, 10:00 PM d. Artificial tears every 8 hours, 8:00 AM, 2:00 PM, 8:00 PM - CORRECT ANSWERS a. It is best to administer diuretics in the morning or early evening to prevent nocturia. Melatonin promotes sleep and rest. Acetaminophen can relieve arthritis pain and help promote rest. Artificial tears, used for dry eyes, will not affect sleep. A nurse caring for patients on a surgical unit should implement which recommendation to promote sleep? Select all that apply a. Keep the room light dimmed during the day. b. Maintain a cool temperature in the room for sleep. c. Keep the door of the room open for fresh air. d. Offer a hypnotic to patients on a regular basis. e. Offer pain medication prior to sleep, as needed. f. Provide earplugs if the patient agrees. - CORRECT ANSWERS b, e, f. The nurse should keep the room cool and provide earplugs and eye masks if desired. The nurse should maintain a bright room environment during daylight hours and dim lights in the evening, keeping the door of the room closed to keep out extraneous noise. Sleep aid medications should only be offered as prescribed with the knowledge that they can become habit forming. A nurse caring for patients in a long-term care facility is implementing interventions to help promote sleep in older adults. Which is the best action for these patients? a. Increase physical activities during the day. b. Encourage short periods of napping during the day. c. Increase fluids during the evening. d. Dispense diuretics during the afternoon hours. - CORRECT ANSWERS a. In order to promote sleep in the older adult, the nurse should encourage daily physical activity such as walking or water aerobics. The nurse discourages napping during the day, decreases fluids at night, and dispenses diuretics in the morning (or early evening when necessary). A patient experiencing menopause tells the nurse at the medical clinic that she would like to try a CAH hormonal sleep aid like her friend uses. What information can the nurse give the patient? 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success a. Melatonin, an over-the-counter hormonal sleep aid, has varied effectiveness. b. Lavender is a hormonal scented sleep aid. c. Lorazepam, a naturally occurring benzodiazepine, is recommended for sleep. d. Valerian is a natural hormonal sleep aid. - CORRECT ANSWERS a. Melatonin, used as a complementary or alternate to traditional pharmacologic agents, is a hormone thought to regulate the sleep-wake cycle. Valerian is an herb; lavender is a plant used for aromatherapy and relaxation. Benzodiazepines are pharmacologic medications used to decrease anxiety and promote sleep and relaxation. After reporting an adult patient's loud snoring and changes in vital signs occurring overnight the patient's health care provider, a nocturnal polysomnography study is prescribed. What teaching will the nurse provide about this test? a. This is a blood test, taken in the evening to evaluate leptin and ghrelin. b. The patient is monitored overnight to evaluate for sleep apnea. c. A patient is evaluated for leg jerking and awakenings during the night. d. Adults, rather than children, can be diagnosed with this test. - CORRECT ANSWERS b. Polysomnography is an overnight sleep study to determine if an individual has sleep apnea and treatment. Leptin and ghrelin are hormones that regulate nutritional intake. Leptin signals the brain to stop eating, whereas ghrelin promotes continued eating. Research suggests that sleep deprivation lowers leptin levels and elevates ghrelin levels, increasing appetite; however, this does not help diagnose sleep apnea. Jerking legs in the early stage of sleep is expected. Both adults and children can benefit from diagnosis of sleep apnea with this test. 1. During postconference, nursing students are exploring definitions of pain and its nature. Which statements should be included in this discussion? Select all that apply. a. "It is whatever the health care provider treating the pain says it is." b. "Pain exists whenever the person experiencing it says it is present." c. "It is an emotional and sensory reaction to tissue damage." d. "Pain is a simple, universal, and easy-to-describe phenomenon." e. "When a cause cannot be identified, pain is psychological in nature." f. "It is classified by duration, location, source, transmission, and etiology." - CORRECT ANSWERS b, c, f. Nurses must respect patients' reports of pain and consider the patient an expert on their pain experience. An accepted definition of pain is that pain is whatever the patient says it is, existing whenever the person says it does, even if the cause is not clearly established." Pain is a complex, unpleasant sensory and emotional experience associated 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success a. Prostaglandins b. Substance P c. Endorphins d. Serotonin - CORRECT ANSWERS c. Endorphins are produced at neural synapses at various points along the CNS pathway. They are powerful pain-blocking chemicals that have prolonged analgesic effects and produce euphoria. It is thought that endorphins are released through pain relief measures, such as relaxation techniques. Prostaglandins, substance P, and serotonin (a hormone that can act to stimulate smooth muscles, inhibit gastric secretion, and produce vasoconstriction) are neurotransmitters or substances that either excite or inhibit target nerve cells. 1. The nurse applies the gate control theory of pain to provide pain relief to a patient with chronic lower back pain. What nursing intervention will help relieve pain by "closing the gate"? a. Encouraging regular use of analgesics b. Applying moist heat to the area at intervals c. Reviewing the pain experience with the patient d. Ambulating the patient after administering medication - CORRECT ANSWERS d. While many analgesics are ordered on a PRN (as needed) basis, patients should be taught that it is more difficult to relieve pain that prevent it. The patient should not wait until pain is severe or unbearable to request pain medication. Few people become addicted to the medications if used for a short period of time. Pain following surgery can be controlled and should not be considered a natural part of the experience that will lessen in time. 1. A postoperative patient asks the nurse about pain management following surgery. What teaching will the nurse provide? a. "Avoid asking for pain medication often, as it can be addictive." b. "It is better to wait until the pain is severe before asking for pain medication." c. "It's natural to have pain after surgery; it will lessen in intensity in a few days." d. "You will be more comfortable if you take the medication at regular intervals." - CORRECT ANSWERS b. The gate control theory states that a limited amount of sensory information can be processed by the nervous system at any given moment. When too much information is sent through, certain cells in the spinal column interrupt the signal as if closing a gate, interfering with pain perception. Nursing measures such as applying warmth to the lower back stimulate the large nerve fibers to close the gate and block the pain. The other choices do not involve attempts to stimulate large nerve fibers that interfere with pain transmission as explained by the gate control theory. 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success 1. The nurse is assessing the pain of a neonate who is admitted to the NICU with a heart defect. Which pain assessment scale would be the best tool to use with this patient? a. CRIES b. COMFORT c. FLACC d. FACES - CORRECT ANSWERS a. The CRIES Pain Scale is a tool intended for use with neonates and infants from 0 to 6 months. The COMFORT Scale, used to assess pain and distress in critically ill pediatric patients, relies on six behavioral and two physiologic factors that determine the level of analgesia needed to adequately relieve pain in these children. The FLACC Scale (F—Faces, L—Legs, A—Activity, C—Cry, C—Consolability) was designed for infants and children from age 2 months to 7 years who are unable to validate the presence or severity of pain. The FACES Scale is used for children who can compare their pain to the faces depicted on the scale. 1. When the nurse assists a patient recovering from abdominal surgery to walk, the nurse observes that the patient grimaces, moves stiffly, and becomes pale. The nurse received in shift report that the patient has consistently refused pain medication. To help promote comfort, which additional data will the nurse gather? Select all that apply. a. Patient's understanding of or fear of taking prescribed analgesics b. Assessment of any current pain c. Presence of anxiety or additional stressors d. Assessment of the surgical incision for infection e. What the patient has eaten to this point Whether the patient is using the incentive spirometer - CORRECT ANSWERS a, b, c, d. While it seems the patient's immediate problem is unrelieved pain because the patient refuses to take pain medication, through further assessment, the nurse can plan to address fears of medication, teach about use of the pump, determine if anxiety is interfering with pain, or an infection is causing increased pain. While decreased oral intake may be a response to pain, the patient's dietary intake will not uncover the underlying reason for refusing medications. Use of the incentive spirometer is not included in pain assessment; rather, it is an intervention to prevent atelectasis. 1. When developing the care plan for a patient with chronic pain, the nurse plans interventions based on the knowledge that chronic pain not related to cancer or palliative/end-of-life care is most effectively relieved through which method? 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success a. Providing the highest effective dose of an opioid on a PRN (as needed) basis b. Using nonopioid drugs conservatively c. Applying multimodal nonpharmacologic and nonopioid pharmacologic therapies d. Administering a continuous intravenous infusion on a regular basis - CORRECT ANSWERS c. Nonpharmacologic and nonopioid pharmacologic therapies (multimodal) are the preferred choices for chronic pain that is unrelated to active cancer, palliative care, or end- of-life care. If progression to opioids becomes necessary, the lowest effective dose of an immediate-release opioid should be initiated first. Ongoing assessment and careful monitoring should guide the prescription of opioids for the management of chronic pain (Dowell et al., 2016). A PRN (as needed) drug regimen has not been proven effective for people experiencing chronic or acute pain. When caring for a patient with acute pain, such as postoperative pain, medication should be offered or requested before pain becomes severe or unbearable. Once pain is adequately treated, such as later in the postoperative course, a PRN schedule may be effective. 1. When assessing pain in a child, the nurse needs to be aware of what considerations? a. Immature neurologic development results in reduced pain sensation b. Inadequate or inconsistent relief of pain is widespread c. Reliable assessment tools are currently unavailable d. Narcotic analgesic use should be avoided - CORRECT ANSWERS b. Health care personnel are placing awareness of pain relief in children as a priority. The evidence supports the fact that children do indeed feel pain, and reliable assessment tools are available specifically for use with children. Opioid analgesics may be safely used with children as long as they are carefully monitored. 1. A pregnant woman has received an epidural analgesic prior to delivery. Assessment for which outcome to the medication will the nurse prioritize? a. Pruritus b. Urinary retention c. Vomiting d. Respiratory depression - CORRECT ANSWERS d. An opioid drug given by way of an epidural catheter or a displaced catheter may result in the occurrence of respiratory depression. Pruritus, urinary retention, and vomiting may occur but are not life threatening. 1. A nurse is assessing a patient receiving a continuous opioid infusion. For which outcome of treatment would the nurse immediately notify the primary care provider? 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success 1. A nurse is feeding an older adult patient with dementia. What intervention will best promote nutritional intake? a. Stroke the underside of the patient's chin to promote swallowing. b. Serve meals in different places and at different times. c. Offer a whole tray of various foods to choose from. d. Avoid between-meal snacks to ensure hunger at mealtime. - CORRECT ANSWERS a. To feed a patient with dementia, the nurse should stroke the underside of the patient's chin to promote swallowing, serve meals in the same place and at the same time, provide one food item at a time since a whole tray may be overwhelming, and provide between-meal snacks that are easy to consume using the hands. 1. A patient with COPD is experiencing anorexia and weight loss. Which intervention would be most helpful in stimulating appetite in this patient? a. Administering pain medication after meals. b. Encouraging the patient's family to bring food from home when possible. c. Scheduling respiratory therapy nebulizer treatments before each meal. d. Reinforcing the importance of eating what is delivered to them. - CORRECT ANSWERS b. Food from home that the patient enjoys may stimulate them to eat. Pain medication should be given before meals, respiratory therapy should be scheduled after meals, and telling the patient what they must eat is no guarantee that they will comply. 1. A nurse is feeding a patient who is experiencing dysphagia. Which nursing intervention will best prevent aspiration? a. Feed the patient solids first and liquids last. b. Place the bed in the semi-Fowler position during feeding. c. Provide a 30-minute rest period prior to mealtime. d. Provide a straw for the patient's beverages and soups. - CORRECT ANSWERS c.The nurse should provide a 30-minute rest period prior to mealtime to promote better swallowing. The nurse alternates solids and liquids when feeding the patient; sits the patient upright or, if on bedrest, elevates the head of the bed at a 90-degree angle; and initiates a nutrition consult for diet modification and food size and/or consistency. Straws are avoided in patients with dysphagia. Assessing breath sounds will help detect aspiration but not prevent it. 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success 1. During interprofessional rounds, the charge nurse and health care provider evaluate patients to determine their need for parenteral nutrition (PN). Which patients will be identified as candidates for this type of nutritional support? Select all that apply. a. Patient with irritable bowel syndrome and intractable diarrhea b. Patient with celiac disease not absorbing nutrients from the GI tract c. Patient who is underweight and needs short-term nutritional support d. Patient who is comatose and needs long-term nutritional support e. Patient who has anorexia and refuses to take foods via the oral route f. Patient with burns who has not been able to eat adequately for 5 days - CORRECT ANSWERS a, b, f. Assessment criteria used to determine the need for PN include an inability to achieve or maintain enteral access, motility disorders, intractable diarrhea, impaired absorption of nutrients from the GI tract, and when oral intake has been or is expected to be inadequate over a 7- to 14-day period. PN promotes tissue healing and is a good choice for a patient with burns who has an inadequate diet with an increased need for calories and nutrients. Oral intake is the best method of feeding; the second-best method is via the enteral route. For short-term use (less than 4 weeks), a nasogastric or nasointestinal route is usually selected. A gastrostomy (enteral feeding) is the preferred route to deliver enteral nutrition in the patient who is comatose because the gastroesophageal sphincter remains intact, making regurgitation and aspiration less likely than with NG tube feedings. Patients who refuse to take food should not be force fed nutrients against their will. 1. A nurse is feeding a patient who reports feeling nauseated and unable to eat what is being offered. What would be the most appropriate initial action of the nurse in this situation? a. Remove the tray from the room. b. Administer an antiemetic and encourage the patient to take small amounts. c. Explore why the patient does not want to eat the food. d. Offer high-calorie snacks such as pudding and ice cream. - CORRECT ANSWERS a. The first action of the nurse when a patient has nausea is to remove the tray, which may have noxious odor, from the room. The nurse may then offer small amounts of foods and liquids such as crackers or ginger ale. The nurse may also administer a prescribed antiemetic and try small amounts of food when it takes effect. 1. A nurse is receiving report on a patient with alcoholism who will be transferred to the medical-surgical unit. Due to long-term alcohol exposure, the nurse plans for administration of which nutrient? a. B vitamins 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success b. Lipids c. Fluids d. C vitamins - CORRECT ANSWERS a. The need for B vitamins is increased in alcoholism because these nutrients are used to metabolize alcohol, thus depleting their supply. Obesity, dehydration, and vitamin C deficiency may be present, but these are not directly related to the effect of alcohol on the GI tract. 1. A nursing student is caring for a patient who had a gastrostomy tube placement 12 hours ago. Which action by the student is correct? a. Using a cotton-tipped applicator dipped into sterile saline solution and gently cleaning around the insertion site b. Washing the area surrounding the tube with a wet washcloth and with soap and water. c. Adjusting the external disk every 3 hours to avoid crusting around the tube. d. Taping a gauze dressing over the site after cleansing it. e. Assessing the gastric residual every 4 hours. f. Discontinuing feedings when gastric residual volume is 120 mL. - CORRECT ANSWERS a. When caring for a new gastrostomy tube, the nurse would use a cotton-tipped applicator dipped in sterile saline to gently cleanse the area, removing any crust or drainage. The nurse would not use a washcloth with soap and water on a new gastrostomy tube but may use this method if the site is healed. Also, once the sutures are removed, the nurse should rotate the external bumper 90 degrees once a day. The nurse should leave the site open to air. If drainage is present, one thickness of precut gauze should be placed under the external bumper and changed as needed to keep the area dry. 1. A nurse is assessing a patient who has been NPO (nothing by mouth) prior to abdominal surgery. The patient is ordered a clear liquid diet for breakfast, to advance to a house diet as tolerated. Which assessments would indicate to the nurse that the patient's diet should not be advanced? a. The patient consumed 75% of the liquids on the breakfast tray. b. The patient tells you they are hungry. c. The patient's abdomen is soft, nondistended, with bowel sounds. d. The patient reports fullness and diarrhea after breakfast. - CORRECT ANSWERS d. Tolerance to a diet can be assessed by the following: absence of nausea, vomiting, and diarrhea; absence of feelings of fullness; absence of abdominal pain and distention; feelings of hunger; and the ability to consume at least 50% to 75% of the food on the meal tray. 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success a. Clear liquid b. Full liquid c. Mechanically altered d. Honeylike liquids - CORRECT ANSWERS c. Mechanically altered diets provide adequate in calories and nutrients and contain chopped, ground, or soft foods. Liquid diets are generally used as transitional diets when eating resumes after acute illness, surgery, or parenteral nutrition. Clear-liquid diets are inadequate in calories, protein, and most nutrients; progression to more nutritious alternatives is recommended as soon as possible. Full-liquid diets include clear liquids plus milk and milk drinks, puddings, custards, plain frozen desserts, pasteurized eggs, cereal gruels, vegetable juices, and milk and egg substitutes in addition to clear liquids. A high-calorie, high-protein supplement is recommended if a full-liquid diet is used for more than 3 days. 1. A nurse is assessing a patient who reports their migraines have become "unbearable." The patient states, "I got laid off from my job last week, and I have two kids in college. I don't know how I'm going to pay for it all." Which effects of physiologic effects of stress would the nurse expect to find in this patient? Select all that apply. a. Increased or decreased appetite b. Changes in elimination patterns c. Decreased pulse and respirations d. Use of ineffective coping mechanisms e. Withdrawal f. Attention-seeking behaviors - CORRECT ANSWERS a, b. Physiologic effects of stress include changes in appetite and elimination patterns as well as increased pulse and respirations. Using ineffective coping mechanisms, becoming withdrawn and isolated, and exhibiting attention-seeking behaviors are psychological effects of stress. 1. A nurse who performs preoperative assessments and teaching prepares patients for postoperative discomfort using anticipatory guidance. What interventions would this nurse use to decrease postoperative stress? a. Teaching rhythmic breathing to perform prior to the procedure b. Telling the patient to mentally place themselves in a pleasant place and breathe in and out slowly c. Explaining about expected incisional discomfort or nausea and describing relief methods d. Suggesting the patient create and focus on a mental image during the procedure to be less responsive to the pain - CORRECT ANSWERS c. Anticipatory guidance focuses on 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success psychologically preparing a person for an unfamiliar or painful event. When the patient knows what to expect through advanced explanation about discomfort, nausea, or pain and available relief measures, the patient's anxiety can be reduced. Rhythmic breathing is a relaxation technique, focusing on a pleasant place and breathing slowly in and out is a meditation technique, and focusing on a mental image to reduce responses to stimuli is a guided imagery technique. While these might be addressed, the other options do not reflect anticipatory guidance or focus on postoperative discomfort. 1. A nurse in a medical practice has assessed a patient reporting abdominal pain, diarrhea, and anxiety. When the health care provider finds no identifiable cause for the symptoms, which actions would the nurse recommend? Select all that apply. a. Keeping a diary identifying sources of stress b. Sleeping 4 hours per night c. Considering previous strengths and coping d. Asking whom the patient relies on for support e. Asking if the patient's partner is abusive f. Assessing for prior psychiatric conditions - CORRECT ANSWERS a, c, d. The sympathetic nervous system reacts to stress with the fight-or-flight response. This response causes increased the heart rate, muscle strength, cardiac output, blood glucose levels, and mental alertness. Increased peristalsis is brought on by the parasympathetic nervous system under normal conditions and at rest. 1. A nurse is assessing the developmental levels of patients in a pediatric office. Which person would a nurse document as experiencing developmental stress? a. Infant who learns to turn over b. School-aged child learning to add and subtract c. Adolescent who is a "loner" d. Young adult who has a variety of friends - CORRECT ANSWERS c. The adolescent who is a loner is not meeting a major task (being a part of a peer group) for that level of growth and development. 1. A nurse in a long-term care facility is caring for patient with a spinal cord injury affecting their sensory and motor reflexes below the waist. Based on the patient's condition, what would be a priority intervention for this patient? a. Taking care with hot beverages to prevent burns 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success b. Providing adequate pain relief measures to reduce stress c. Monitoring for depression related to social isolation d. Offering meals high in carbohydrates to promote healing - CORRECT ANSWERS a. A patient with a damaged neurologic reflex arc has a diminished pain reflex response. This diminished sensation and motor response places the patient at risk for burns. All patients should be provided adequate pain relief, but this is not a priority. Monitoring for depression would be an intervention for this patient but is not related to the damaged neurologic reflex arc. A patient who is immobile should eat a well-balanced diet. 1. A nurse in the emergency department receives a patient rescued from a building fire. The firefighter giving the handoff report tells the nurse the building collapsed immediately after they removed the patient from the building. The nurse notes the patient is experiencing the alarm phase of the fight-or-flight response. What assessment findings support the nurse's observation? Select all that apply. a. Rapid breathing b. Hypotension c. Restlessness d. Withdrawn demeanor e. Tachycardia - CORRECT ANSWERS a, c, e. The sympathetic nervous system initiates the fight-or-flight response, preparing the body to fight a stressor or run from it. This phase of the alarm reaction, called the shock phase, is characterized by an increase in energy levels, oxygen intake, cardiac output, blood pressure, and mental alertness. During the second phase, called the countershock phase, there is a reversal of body changes. Hypotension and withdrawn demeanor represent the countershock phase. 1. Nurses working in a trauma intensive care unit state they experience a high level of stress. Which stressor are they likely to encounter? a. Nurse manager support for equitable assignments b. Health care benefits c. Debriefings after the death of a patient d. Incivility by team members or bullying - CORRECT ANSWERS d. Incivility encompasses rude or discourteous actions that negatively affect others. Incivility can escalate to bullying, which is defined as repeated, ongoing actions that intend to harm another person. This includes humiliation, offensive speech or actions, or other methods of causing distress. The other options exist in a positive work environment. 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success "It may be best to not think about this person until after the wedding." - CORRECT ANSWERS a. Although identifying the problem may be difficult, a solution to a crisis situation is impossible until the problem is identified. 1. A nurse is performing an assessment of a patient who is 8 months' pregnant. The patient states, "I worry about being able to handle becoming a mother." The nurse plans interventions for which problem? a. Poor coping skills b. Denial about the impending birth c. Uncertainty and anxiety due to change in role d. Low self-esteem and fear of parenting - CORRECT ANSWERS c. The nurse prepares a care plan focusing on anxiety, which can develop in a situational/maturational crises or changes in role status. There is insufficient data to determine whether the patient is demonstrating poor coping, referring to an inability to appraise stressors or use available resources. The patient is not displaying denial, as she is consciously discussing the anxiety rather than attempting to disavow the knowledge or meaning of the impending birth. There is no indication the patient has feelings of worthlessness (poor self-esteem) but rather expresses concern about the role change as she becomes a mother. 1. A parent bringing their toddler for a visit to the pediatric clinic tells the nurse that after work their partner yelled at the child for dropping a fork. Later the patient learned the partner's supervisor had been angry about the contents of a report that was submitted. The nurse explains it is likely their partner was using which coping mechanism? a. Denial b. Sublimation c. Displacement d. Dissociation - CORRECT ANSWERS c. The nurse can explain that the patient's partner used the coping mechanism displacement, by transferring (displacing) their anger to a "safe" target. Another example is an angry person kicking a chair or slamming a door. The nurse can encourage the patient to discuss this with their partner. 1. A nursing student tells the clinical professor that they hate when they feel anxious before performing new procedures. They state they do not sleep well the night before, feel restless, and have increased alertness. How does the professor best respond to this concern? a. Suggesting the student seems worried about failing clinical and should seek professional help 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success b. Stating that we cannot diagnose students, but these symptoms of mild anxiety can aid in learning and growth c. Suggesting the student is in denial about the need to increase their clinical grade and should meet with the course faculty d. Asking if they have considered speaking to someone about their panic disorder and recommend a provider - CORRECT ANSWERS b. The professor can normalize the student's experience by explaining that mild anxiety is present in day-to-day living. It can increase alertness and perceptual fields (e.g., vision and hearing) and motivate learning and growth. Although mild anxiety may interfere with sleep, it also facilitates problem solving. Mild anxiety is often manifested by restlessness and increased questioning. The other options call attention to problems that may not exist. 1. A nurse in a medical practice has assessed a patient reporting abdominal pain, diarrhea, and anxiety. With no identifiable cause for the pain, which actions to reduce stress would the nurse recommend? Select all that apply. a. Keeping a diary identifying sources of stress b. Sleeping 4 hours per night c. Considering previous strengths and coping mechanisms d. Asking whom the patient relies on for support e. Asking if their partner is abusive f. Assessing for prior psychiatric conditions - CORRECT ANSWERS a, c, d. Keeping a diary of sources of stress can help identify the problem, which is the first step in stress management. The nurse can help the patient identify supports and their strengths. The nurse should recommend sleeping 7 to 9 hours nightly. The nurse would not infer there is a problem of abuse or a psychiatric condition as a cause of their symptoms. Abuse is assessed for routinely, often at the start of the interview, but not in the context of this situation. 1. When caring for an older adult in a geriatric practice who seems anxious and inattentive, the nurse plans to discuss stressors particular to the older adult. For which stressors will the nurse assess? Select all that apply. a. Concern over memory loss b. Acting as the designated driver for friends c. Death of spouse last month d. Inappropriate use of alcohol e. Successful cataract surgery 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success f. Recent mobility issues - CORRECT ANSWERS a, c, d, f. Stressors of the older adult include declining physical and/or mental capabilities; invasive or health-related tests, examinations, or surgeries (even those with a positive outcome can produce stress, especially related to declining vision); alcohol abuse; diagnosis of chronic illnesses; loss of spouse or significant other; retirement; increased social isolation; loss of independence in living arrangements, driving, or activities of daily living; and chronic pain. The ability to still drive is not considered a stressor. 1. A nurse midwife is assisting a patient whose birth plan states she is firmly committed to natural childbirth. When informed the infant is in distress and a cesarean delivery is necessary, the pregnant patient sobs inconsolably, calling herself a failure. The nurse offers emotional support based on what likely types of losses? Select all that apply. a. Actual b. Perceived c. Psychological d. Anticipatory e. Physical f. Maturational - CORRECT ANSWERS a, b, c. The losses experienced by the pregnant patient are actual, perceived, and psychological. Actual loss can be recognized by others as well as by the person sustaining the loss; perceived loss is experienced by the person but is intangible to others; and psychological loss is a loss that is felt emotionally as opposed to physically. Anticipatory loss occurs when one grieves prior to the actual loss; physical loss is tangible and perceived by others; and maturational loss is experienced as a result of natural developmental processes. 1. A hospice nurse who cared for a dying patient and their family documents that the family is experiencing a period of mourning. Which behaviors would the nurse expect to see at this stage? Select all that apply. a. The family arranges for a funeral for their loved one. b. The family arranges for a memorial scholarship for their loved one. c. The coroner pronounces the patient's death. d. The family arranges for hospice for their loved one. e. The patient is diagnosed with terminal cancer. f. The patient's daughter writes a poem expressing her sorrow. - CORRECT ANSWERS a, b, f. Mourning refers to the actions and expressions of grief, including the symbols and ceremonies (e.g., a funeral or final celebration of life) that make up the outward expressions 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success written by a ventilator-dependent patient "help me end my suffering, I don't want to live anymore." Which nursing response is consistent with the ANA's position? a. "I will do everything possible to keep you comfortable but will not administer medication to cause your death." b. "Being removed from the ventilator is a form of active euthanasia, which is not supported by the nurses' code of ethics." c. After exhausting every intervention to keep a dying patient comfortable, the nurse says, "Let's talk about when and how you want to die." d. "I'm personally opposed to assisted suicide, but I'll find you a colleague who can help you." - CORRECT ANSWERS a. The ANA Code of Ethics states that the nurse "should provide interventions to relieve pain and other symptoms in the dying patient consistent with palliative care practice standards and may not act with the sole intent to end life" (2015, p. 3). Removing mechanical ventilation or other life support at the patient's request or request of the surrogate when treatment is futile is not performed with the sole intent to end life but to promote dignity and comfort. Nurses should be prepared to respond to the request: "Nurse, please help me die...." 1. A patient with end-stage breast cancer has been in the medical intensive care unit for 3 weeks. Her husband tells the nurse that his wife was very clear about not wanting aggressive treatment that would merely prolong her dying. Which type of order could the nurse suggest the husband discuss with his wife's health care provider? a. Comfort Measures Only b. Do Not Hospitalize c. Living Will d. Slow Code Only - CORRECT ANSWERS a. The nurse could suggest that the husband speak to the health care provider about a Comfort Measures Only order in which the goal of treatment is a comfortable, dignified death, and further life-sustaining measures have been declined. A Do-Not-Hospitalize order is often used for patients in long-term care and other residential settings who refuse hospitalization for further aggressive treatment. A living will is a document in which the patient provides specific instructions about the kinds of health care that should be provided or foregone in particular situations in which they are unlikely to recover. A Slow Code refers to a delay in calling a code and beginning resuscitation efforts until these measures will be ineffective. This is not consistent with current best practice and may be forbidden in certain facilities. A nurse could be charged with negligence in the event of a Slow Code and resulting patient death. 1. A nurse in the intensive care unit is preparing a patient's family for terminal weaning from mechanical ventilation. What nursing actions would facilitate this process? Select all that apply. 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success a. Offering the family information about the advantages and disadvantages of continued ventilatory support b. Explaining to the family what will happen at each phase of the weaning and offer support c. Validating orders for sedation and analgesia to promote comfort and dignity d. Explaining that death occurs quickly after the patient is removed from the ventilator e. Teaching the family that the decision for terminal weaning must be made by the primary care provider f. Arranging mandatory counseling for the patient and family to assist them in making this end-of-life decision - CORRECT ANSWERS a, b, c. A nurse's role in terminal weaning is to assist patients and families in the decision-making process by offering helpful information about the benefits and burdens of continued ventilation. The nurse teaches what to expect if terminal weaning is initiated, including the use of sedation and analgesia for patient comfort. Supporting the patient and family and managing sedation and analgesia are critical nursing responsibilities. In some cases, competent patients decide that they want to discontinue their ventilatory support; more often, the surrogate decision makers determine that continued ventilatory support is futile. The nurse would not predict the time until death. Once removed from the ventilator, a patient may not resume spontaneous breathing or may breathe on their own, living for hours, days, or rarely, longer. Counseling may be arranged if requested but is not mandatory for decision making. 1. The parents of an infant in the neonatal intensive care unit (ICU) for several months also have a 22-month-old child at home. The nurse notes the parents seem chronically fatigued, express guilt about neglecting their child at home, have been short tempered, and express anxiety about their continued ability to manage their family. The nurse plans to address which of these health problems in the plan of care? a. Dysfunctional Grief b. Fear about Being a Burden to Others c. Impaired Ability of Caregiver to Perform Caretaking d. Impaired Health Maintenance - CORRECT ANSWERS c. Impaired ability of a caregiver to perform caretaking applies to these parents. Even with a positive outcome, the infant in the ICU is likely to be discharged with many needs, which may still impact them and their other child. Grief is an expression of loss, but the focus here is on the parents' exhaustion and coping. The health problem of being a burden refers to a patient's fear, rather than the caregiver. There is no specific information about the health maintenance needs of the child, rather, in this situation, the parents are the focus of care. 1. A nurse is caring for terminally ill patients in a long-term care setting. Which nursing action is appropriate during end-of-life care? 2023 Rn Test 3 Nclex Questions And Answers Updated 2024/2025 All Answers 100% Correct Detailed Best Graded To Score A+ For Success a. Avoiding disturbing a comatose patient by speaking to them while providing care b. Holding the hand of a dying patient and crying with the patient and family c. Requesting a social work consult for family members with multiple complaints about the care d. Performing hygiene for the patient because it is easier than having the patient help - CORRECT ANSWERS b. The nurse should not be afraid to show compassion and empathy for the dying person, including crying with the patient or family. The sense of hearing is believed to be the last sense to leave the body before death; therefore, the nurse should explain care to comatose or unresponsive patients. The nurse should address caregiver role endurance by actively listening to family members. Encouraging the dying patient to remain active and participate in care for as long as possible is appropriate, rather than taking over self-care measures. 1. After validating an autopsy is not planned, a new graduate nurse provides postmortem care. Which action requires the preceptor to correct the graduate? a. Leaving the patient in a sitting position at the family's request b. Placing identification tags on both the shroud and the ankle c. Removing soiled dressings and tubes, while washing the body d. Ensuring a death certificate is issued and signed - CORRECT ANSWERS a. Because the body should be placed in normal anatomic position to avoid pooling of blood, leaving the body in a sitting position is contraindicated. The other actions are appropriate nursing responsibilities related to postmortem care. 1. The family of a patient who has just died asks for privacy and supplies to wash their loved one's body. How does the nurse best respond? a. Inform the family that there is no need for them to wash the body since the funeral home typically does this. b. Explain that hospital policy forbids their being alone with the deceased patient. c. Provide the requested the supplies and maintain a watchful eye to ensure they maintain the patient's dignity. d. Provide the requested supplies, assess if this request is linked to religious or cultural customs, and offer assistance. - CORRECT ANSWERS d. The family may want to wash the body for personal, religious, or cultural reasons and should be allowed to do so. This action may reflect caring, the last service to a loved one, or promote acceptance of death.