NCLEX-RN
Implementation Questions
Extract:
Question 1 of 5
A client diagnosed with obsessive-compulsive rituals often misses the unit's morning activities because of a bed-making ritual. What nursing action would be therapeutic?
Correct Answer: D
Rationale: Reflective feedback acknowledges the client's behavior. Verbalizing disapproval and discussing social implications would increase the client's anxiety and reinforce the need to perform the ritual. The client is usually aware of the implications of the behavior. Helping with the ritual is nontherapeutic and also reinforces the behavior.
Question 2 of 5
During the assessment, the nurse notes that the child's genitals are swollen. The nurse suspects that the child is being sexually abused. Which action by the nurse is of primary importance?
Correct Answer: B
Rationale: The primary legal responsibility of the nurse when child abuse is suspected is to report the case. All 50 states require health care professionals to report all cases of suspected abuse. Although documenting the assessment findings, assisting the family, and referring the family to appropriate resources and support groups is important, the primary legal responsibility is to report the case. Although the remaining options are appropriate, reporting the findings has priority.
Question 3 of 5
The nurse is checking the fundus of a postpartum woman and notes that the uterus is soft and spongy. Which nursing action is appropriate initially?
Correct Answer: C
Rationale: If the fundus is boggy (soft), it should be massaged gently until it is firm and the client is observed for increased bleeding or clots. Option 1 is an inappropriate action at this time. The nurse should document the fundal position, consistency, and height; the need to perform fundal massage; and the client's response to the intervention. The primary health care provider will need to be notified if uterine massage is not helpful.
Question 4 of 5
The nurse responds to a call bell and finds a client lying on the floor after a fall. The nurse suspects that the client's arm may be broken. Which immediate action should the nurse take?
Correct Answer: A
Rationale: When a fracture is suspected, it is imperative that the area be splinted before the client is moved. Emergency help should be called for if the client is external to a hospital, and a primary health care provider is called if the client is hospitalized. Vital signs would be taken, but this is not the immediate action. The primary health care provider rather than the nurse prescribes an x-ray examination. The nurse should remain with the client and provide realistic reassurance. Although the details of the fall are important, such a discussion is not an immediate need.
Question 5 of 5
The nurse is caring for a client who is scheduled an arthrogram involving the use of a contrast medium. Which action by the nurse is the priority?
Correct Answer: A
Rationale: Because of the risk of allergy to contrast medium, the nurse places the highest priority on assessing whether the client has an allergy to iodine or shellfish. The nurse also reinforces information about the test and reminds the client about the need to remain still during the procedure. It is helpful to have the client void before the procedure for comfort.