NCLEX-RN
Basic Adult Health Care NCLEX Heart Questions Questions
Extract:
Question 1 of 5
A very elderly, drowsy client with fragile skin is being transferred from the surgery cart to the bed. How should the nurse plan to direct the transfer to prevent skin shearing?
Correct Answer: B
Rationale: Using a drawsheet with two people (one per side) and one at the head minimizes skin shearing by providing support and controlled movement, suitable for a drowsy elderly client.
Question 2 of 5
After insertion of a nasoenteric tube, the nurse should place the client in which position?
Correct Answer: C
Rationale: The semi-Fowler's position facilitates drainage and decompression via the nasoenteric tube while promoting comfort and preventing aspiration. Supine, right side-lying, or upright positions are less effective for this purpose. CN: Physiological adaptation; CL: Synthesize
Question 3 of 5
Which of the following clinical manifestations does the nurse most likely observe in a client with Hodgkin's disease?
Correct Answer: B
Rationale: Hodgkin's disease typically presents with painless, enlarged cervical lymph nodes, often the first sign noticed. Difficulty swallowing, breathing, or liver fullness are less common or occur later.
Question 4 of 5
Which of the following skin preparations would be best to apply around the client's colostomy?
Correct Answer: A
Rationale: Karaya is a natural skin barrier that protects the skin around the stoma from irritation and is commonly used in ostomy care. Petroleum jelly is not suitable as it can interfere with adhesion of the ostomy appliance, and antiseptic cream is not typically used for routine skin protection around a stoma. CN: Physiological adaptation; CL: Apply
Question 5 of 5
The client who has been hospitalized with pancreatitis does not drink alcohol because of her religious convictions. She becomes upset when the physician persists in asking her about alcohol intake. The nurse should explain that the reason for these questions is that:
Correct Answer: A
Rationale: Alcohol is a primary cause of acute pancreatitis, so questioning its use (
A) is essential to identify etiology. Interference with tests (
B), general alcoholism screening (
C), or disregarding beliefs (
D) are not accurate explanations.