NCLEX-RN
NCLEX RN Exam Prep Questions
Extract:
Question 1 of 5
When cleansing the genital area during perineal care, the nurse should _____________.
Correct Answer: B
Rationale: During perineal care, when cleansing the genital area of an uncircumcised male patient, it is crucial to retract the foreskin to clean the area underneath. This helps in the removal of smegma, a substance that can accumulate and lead to bacterial growth and infection if not cleaned properly. The foreskin should then be replaced back to its original position after cleaning to ensure proper hygiene and prevent any potential complications.
Choices A, C, and D are incorrect because they do not address the specific care required for an uncircumcised penis, which involves retracting and replacing the foreskin.
Question 2 of 5
A nurse is preparing to irrigate a client's indwelling catheter through a closed, intermittent system. Which of the following steps must the nurse take as part of this process?
Correct Answer: D
Rationale: When performing closed intermittent system catheter irrigation, the nurse should use sterile solution at room temperature with sterile technique. It is important to position the client comfortably for easy access to the catheter site and to assess the abdomen during the procedure. Clamping the catheter should be done below the level of the injection port, not above. The correct step is to inject sterile solution through the injection port into the catheter, allowing the fluid to travel up the catheter to irrigate the tubing and the bladder.
Question 3 of 5
Which of the following is an example of physical abuse?
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.
Question 4 of 5
In which of the following ways can a nurse promote sleep for a client experiencing insomnia?
Correct Answer: D
Rationale: A nurse can promote sleep for a client experiencing insomnia by addressing factors that may hinder sleep. Cold feet can disrupt sleep, so providing the client with socks to keep their feet warm can enhance comfort and aid in promoting sleep. The correct answer focuses on a direct intervention to address a specific issue that can impact sleep quality.
Choices A, B, and C do not directly address the issue of cold feet, which is a common problem that can interfere with sleep in individuals with insomnia. Assisting the client to use the bathroom, giving a massage in the morning, or tucking in bed sheets tightly do not target the discomfort caused by cold feet, making them less effective interventions for promoting sleep in this scenario.
Question 5 of 5
A client has died approximately one hour ago. The nurse notes that the client's temperature has decreased in the last hour since their death. Which of the following processes explains this phenomenon?
Correct Answer: C
Rationale: Algor mortis occurs after death when the body's circulation stops, and the client's temperature begins to fall. The client's temperature will drop by approximately 1.8 degrees per hour until it reaches room temperature. During algor mortis, the client's skin gradually loses its elasticity. Rigor mortis refers to the stiffening of the body after death due to chemical changes in the muscles. Postmortem decomposition is the breakdown of tissues after death. Livor mortis is the pooling of blood in the dependent parts of the body, causing a purple-red discoloration.