NCLEX RN Exam Prep - Nurselytic

Correct Answer: C

Rationale: When a client with a colostomy is preparing for irrigation, it is essential to consider contraindications that could pose risks or worsen the client's condition. Diverticulitis is a contraindication for colostomy irrigation because the inflamed diverticula could be further irritated by the flushing action during irrigation, potentially leading to complications. An incontinent ostomy, irregular bowel routine, or presence of fecal material in the colostomy bag are not specific contraindications for irrigation and can be managed through appropriate techniques and interventions.

Correct Answer: C

Rationale: Circumduction involves moving a limb in a circular pattern. In this scenario, the nurse is performing circumduction by moving the leg in a circular motion, engaging the muscles of the gluteus maximus and gluteus medius.
Choice A, 'Bending the leg at the knee,' is incorrect as it describes flexion and extension movements.
Choice B, 'Turning the foot inward and outward,' refers to inversion and eversion movements of the foot, not circumduction.
Choice D, 'Moving the leg forward and up,' describes flexion and abduction movements, not circumduction.

Correct Answer: A

Rationale: The correct answer is 'A slap to the person's hand.' Slapping, hitting, and punching are clear examples of physical abuse. Physical abuse involves actions that can cause physical harm or injury to a person.
Choice B, 'Threatening the person,' falls under the category of emotional or psychological abuse, where threats can cause fear and emotional distress but do not involve physical harm.
Choice C, 'Ignoring and isolating a person,' is a form of neglect or emotional abuse, not physical abuse.
Choice D, 'Leaving a patient soiled for hours,' is an example of neglect or lack of proper care, which is also not classified as physical abuse.

Correct Answer: D

Rationale: The lowest priority patient care task in this scenario is addressing the emotional need of the patient who is crying because his daughter did not visit him today. While emotional support is important, the other needs - providing water, assisting to the bathroom, and addressing chest pain - are physical needs that must take priority as they directly impact the patient's well-being and health. It is crucial to acknowledge and address emotional needs but in this situation, the physical needs of the patients should be addressed first.

Correct Answer: B

Rationale: When turning an immobile bedridden client without assistance, the best action to ensure client safety is to put bed rails up on the side of the bed opposite from the nurse. This is important because the nurse can only stand on one side of the bed, so having bed rails on the opposite side prevents the client from falling out of bed. Option A, which suggests securely grasping the client's arm and leg, can potentially cause client injury to the skin or joints. Options C and D, correctly positioning and using a turn sheet, and lowering the head of the client's bed slowly, respectively, are useful techniques during client turning but are of lower priority in terms of safety compared to the use of bed rails.