NCLEX-PN
Nclex Exam Cram Practice Questions Questions
Extract:
Question 1 of 5
A primigravida begins labor when her family is unavailable and she is alone. She is very upset that her family is not with her. Which approach can the nurse take to meet the client's needs at this time?
Correct Answer: A
Rationale: In this situation, the best approach for the nurse is to ask whether another individual wants to be the client's support person. This empowers the client to choose someone to be with her until her family can join her, providing the needed support and comfort. Assuring her that a nursing staff member will be with her at all times (
Choice
B) may not fully address her emotional needs for familiar support. Telling her you will try to locate her family (
Choice
C) may not be feasible in the immediate situation and may not provide immediate emotional support. While reinforcing the woman's confidence in her own abilities (
Choice
D) is important, it may not fully address her current need for emotional support and presence of a companion.
Question 2 of 5
What is the most likely reason for a hospitalized adult client who routinely works from midnight until 8 a.m. to have a temperature of 99.1°F at 4 a.m.?
Correct Answer: D
Rationale: The correct answer is 'circadian rhythm.' Circadian rhythms are biological cycles that last about 24 hours. The sleep-wake cycle is closely tied to circadian rhythms, affecting body temperature. Normally, core body temperature drops during sleep, reaching its 24-hour low around 4 a.m. In this case, the client's temperature of 99.1°F at 4 a.m. is likely due to the disruption of their circadian rhythm caused by working from midnight until 8 a.m.
Choices A, B, and C are incorrect because delta sleep, slow brain waves, and pneumonia do not directly explain the temperature fluctuation based on circadian rhythm.
Question 3 of 5
When providing perineal care to a female client, how should the nurse perform the procedure?
Correct Answer: A
Rationale: When providing perineal care to a female client, the nurse should wear gloves and wash the perineal area from front to back. This technique helps prevent the introduction of E. coli and other bacteria into the urethra, reducing the risk of urinary tract infections. Washing from back to front can introduce bacteria from the anal area to the urethra, leading to infections. Performing the procedure without gloves or having the client perform all care does not adhere to infection control practices. Pouring water from a sterile bottle alone may not ensure proper cleansing and infection prevention.
Therefore, choices B, C, and D are incorrect as they do not follow proper perineal care guidelines.
Question 4 of 5
A client who has undergone a total hip replacement is told that she will need to go to an extended care rehabilitation facility for therapy before going home. Which member of the healthcare team should the nurse ask to plan the discharge and transition from the hospital to the rehabilitation facility?
Correct Answer: D
Rationale: In this scenario, the appropriate member of the healthcare team to plan the discharge and transition from the hospital to the rehabilitation facility is the social worker. Social workers are trained to provide counseling services, emotional support, arrange placements in care facilities, and locate financial resources for clients. While clergy provide spiritual support and guidance, physical therapists assist in physical treatments, and occupational therapists help with activities of daily living, the social worker is best suited to address the client's needs related to discharge planning and transition.
Therefore, the correct answer is the social worker.
Question 5 of 5
For which of the following conditions might blood be drawn to assess uric acid levels?
Correct Answer: B
Rationale: Uric acid levels are commonly assessed in patients with gout. Gout is a type of arthritis caused by the buildup of uric acid crystals in the joints, leading to inflammation and pain. Monitoring uric acid levels helps in diagnosing and managing gout. Asthma, diverticulitis, and meningitis are not conditions where blood tests for uric acid levels are typically necessary. Asthma is a respiratory condition, diverticulitis involves inflammation of the digestive tract, and meningitis is an infection of the meninges in the brain and spinal cord.