NCLEX-RN
Free NCLEX RN Questions on Health Promotion and Maintenance Questions
Question 1 of 5
When preparing the client with a spinal cord injury who is experiencing bladder spasms and reflex incontinence for discharge to home, the nurse should provide which instruction to prevent the problem?
Correct Answer: A
Rationale: Caffeine in the diet can contribute to bladder spasms and reflex incontinence; thus, it should be eliminated in the diet of the client with a spinal cord injury. The self-monitoring of the temperature is useful to detect infection, but it does nothing to alleviate bladder spasms. Limiting fluid intake does not prevent spasm, and it could place the client at further risk for urinary tract infection. Self-catheterization every 2 hours is too frequent and serves no useful purpose.
Question 2 of 5
The nurse has taught the client with pleurisy about measures to promote comfort during recuperation. The nurse determines that the client has understood the information if the client states the need to follow which instruction?
Correct Answer: D
Rationale: The client with pleurisy should splint the chest wall during coughing and deep breathing. Taking small, shallow breaths promotes atelectasis. The client should take medication cautiously so that adequate coughing and deep breathing are performed and an adequate level of comfort is maintained. The client may also lie on the affected side to minimize the movement of the affected chest wall.
Question 3 of 5
The nurse has completed instructions regarding diet and fluid restriction for the client diagnosed with chronic kidney disease. The nurse determines that the client understands the information presented if the client selected which dessert from the dietary menu?
Correct Answer: D
Rationale: For fluid-restricted diets in chronic kidney disease, clients should avoid foods liquid at room temperature like Jell-O, sherbet, and ice cream, which count as fluid intake. Angel food cake is a solid dessert, allowing more fluid intake by drinking to alleviate thirst.
Question 4 of 5
Cyclophosphamide is prescribed for the client diagnosed with breast cancer, and the nurse provides instructions to the client regarding the medication. Which statement by the client indicates the need for further teaching?
Correct Answer: C
Rationale: Cyclophosphamide can cause hemorrhagic cystitis, requiring copious fluid intake (2–3 liters/day) to prevent it, not fluid restriction. Hair regrowth, reporting sore throat (indicating infection), and avoiding live virus vaccine contacts are correct due to immunosuppression.
Question 5 of 5
The nurse is precepting a student nurse on the medical-surgical unit who is caring for a client with a T-tube. Which statement by the student nurse regarding the care of the tube indicates a need for further teaching?
Correct Answer: D
Rationale: Clamping the T-tube during nausea or vomiting risks pressure buildup; it should be reported instead. Other statements are correct.