NCLEX-RN
NCLEX RN Exam Prep Questions
Extract:
Question 1 of 5
A client is preparing to administer an enema to a 64-year-old client. Which of the following actions of the nurse is most appropriate?
Correct Answer: B
Rationale: When administering an enema to a client, the nurse should place the client in the Sims' position for easy access. The correct action is to apply lubricating jelly to the tip of the catheter before insertion to facilitate a smoother procedure. It is essential to instill a maximum of 750 to 1000 cc of fluid for an adult client, not just 30cc. Following administration, the nurse should ask the client to hold the solution for at least 5 minutes to allow for the desired effect of the enema.
Therefore, choice B is the most appropriate action, as choices A, C, and D are incorrect due to inaccuracies in positioning, enema volume, and retention time.
Question 2 of 5
A client is complaining of pain that starts in the shoulder and travels down the length of his arm. This type of pain is referred to as:
Correct Answer: C
Rationale: Radiating pain is the correct term for pain that originates in one part of the body and extends to other related areas. In this scenario, the pain starting in the shoulder and traveling down the arm describes radiating pain. Referred pain (
Choice
A) is pain felt at a site different from the actual origin of the pain. Superficial pain (
Choice
B) is pain that arises from the skin or tissues just beneath it. Precipitating pain (
Choice
D) refers to pain that is triggered by specific actions or events, not the characteristic described in the question.
Question 3 of 5
The nurse should wash from the ________________________ when washing a patient's eye area.
Correct Answer: B
Rationale: When washing a patient's eye area, it is important to start from the inner canthus (closest to the nose) and move towards the outer canthus. This direction prevents any contaminants or debris from the outer area of the eye from moving towards the inner, more sensitive area.
Choices C and D are incorrect as they pertain to the nasal passages (nares), which are not relevant when washing the eye area.
Question 4 of 5
You see a sign over Mary Jones' bed when you arrive at 7 am to begin your day shift. The sign says, 'NPO'. Ms. Jones is on a regular diet. The patient asks for milk and some crackers. You _____________.
Correct Answer: D
Rationale: The correct answer is that you cannot give her anything to eat or drink. 'NPO' is the standard abbreviation for 'nothing by mouth,' indicating that the patient should not consume any food or liquids. It is crucial to adhere to this restriction to prevent any potential harm or complications in the patient's condition.
Choices A, B, and C are incorrect because 'NPO' clearly specifies that the patient should not have anything to eat or drink, including milk and crackers. Providing these items could lead to adverse effects, so it is essential to follow the 'NPO' directive strictly.
Question 5 of 5
A client is being instructed on how to use crutches. Which of the following information should be included in the teaching?
Correct Answer: B
Rationale: When instructing a client on how to use crutches for ambulation, it is important to emphasize keeping the crutch tips dry to prevent slipping while bearing weight on them. Moisture on the crutch tips can lead to accidents.
Therefore, the correct answer is to dry the crutch tips with a paper towel if they become wet.
Choice A, placing the majority of body weight on the axilla, is incorrect as the weight should be borne through the hands, not the axilla, to avoid nerve damage.
Choice C, using the crutches to lift both feet simultaneously when ascending stairs, is incorrect as the client should ascend stairs by placing weight on the unaffected leg first, followed by the crutches and then the affected leg. This method provides stability and safety during stair climbing.