NCLEX Questions, NCLEX Practice Test RN Questions, NCLEX-RN Questions, Nurselytic

Questions 158

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Question 1 of 5

A client with inflammatory bowel disease (IBD) requires an ileostomy. The nurse would instruct the client to do which of the following measures as an essential part of caring for the stoma?

Correct Answer: D

Rationale: Meticulous cleansing of the peristomal skin prevents irritation and infection, essential for ileostomy care. Stoma massage (
A) is unnecessary, high-fiber foods like nuts (
B) may cause blockages, and limiting fluids (
C) risks dehydration.

Question 2 of 5

The nurse is caring for a client with a history of diverticulitis. Which meal selection indicates that the client understands the dietary teaching?

Correct Answer: B

Rationale: Clients with diverticulitis should follow a low-residue diet during flare-ups to reduce bowel irritation. Baked chicken, rice, and an apple are low in fiber and suitable. The other options contain high-fiber or irritating foods (e.g., spinach, whole wheat, garlic).

Question 3 of 5

A 23-year-old male client is admitted to the chemical dependency unit with a medical diagnosis of alcoholism. He reports that the last time he drank was 3 days ago, and that now he is starting to 'feel kind of shaky.' Based on the information given above, nursing care goals for this client will initially focus on:

Correct Answer: D

Rationale: Self-concept and self-esteem problems may emerge during the client's treatment, but these are not immediate concerns. Interpersonal issues may become evident during the course of the client's treatment, but these are also not immediate areas of concern. Improving individual coping skills is generally a primary focus in the treatment and nursing care of persons with substance abuse problems. However, this is still not the immediate concern in this client situation. Correction of fluid and electrolyte status and vitamin deficiencies, as well as prevention of delirium, is the immediate concern in the care of this client.

Question 4 of 5

Which of the following procedures is necessary to establish a definitive diagnosis of breast cancer?

Correct Answer: D

Rationale: Diaphanography, also known as transillumination, is a painless, noninvasive imaging technique that involves shining a light source through the breast tissue to visualize the interior. It must be used in conjunction with a mammogram and physical examination. Mammography is a useful tool for screening but is not considered a means of diagnosing breast cancers. Thermography is a pictorial representation of heat patterns on the surface of the breast. Breast cancers appear as a 'hot spot' owing to their higher metabolic rate. Biopsy either by needle aspiration or by surgical incision is the primary diagnostic technique for confirming the presence of cancer cells.

Question 5 of 5

The local health clinic recommends vaccination against influenza for all its employees. The influenza vaccine is usually given annually in:

Correct Answer: A

Rationale: Influenza vaccines are typically administered in November, before the peak flu season, to ensure immunity during winter months.

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