NCLEX-PN
Nclex Exam Cram Practice Questions Questions
Extract:
Question 1 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 2 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 3 of 5
A client with which of the following conditions is at risk for developing a high ammonia level?
Correct Answer: D
Rationale: Cirrhosis is the correct answer. In cirrhosis, the liver is unable to detoxify ammonia to urea, leading to an accumulation of ammonia in the blood. This can result in hepatic encephalopathy, a condition characterized by high ammonia levels affecting brain function. Renal failure (
Choice
A), psoriasis (
Choice
B), and lupus (
Choice
C) are not directly associated with an increased risk of high ammonia levels as seen in cirrhosis.
Question 4 of 5
When suctioning a client, what is the usual amount of time the nurse should spend for each suction pass?
Correct Answer: B
Rationale: Ten seconds is the usual amount of time the nurse should spend for each suction pass. Two seconds is not enough time to effectively remove secretions, while 20 and 30 seconds are too long and could lead to hypoxia and tissue trauma.
Therefore, the correct choice is 10 seconds, as it strikes a balance between removing secretions adequately and minimizing the risks associated with prolonged suctioning.
Question 5 of 5
What is a predisposing factor for cancer of the tongue?
Correct Answer: A
Rationale:
Tobacco use is a well-established predisposing factor for cancer of the tongue. Smoking or chewing tobacco can lead to the development of oral cancers, including those affecting the tongue. Obesity, sun exposure, and eating sweets are not directly linked to an increased risk of tongue cancer. Obesity may be associated with other types of cancer, sun exposure can lead to skin cancer, and eating sweets is not a known risk factor for tongue cancer.
Therefore, the correct answer is tobacco use, as it has a strong association with the development of tongue cancer, making it a significant predisposing factor.