NCLEX PN Test Questions
Question 1 of 5.
The client with a colostomy does not feel that the irrigating solution has drained completely. The nurse can enhance the effectiveness of the colostomy irrigation by telling the client to:
A. Massage the abdomen gently.
B. Reduce the amount of irrigation solution.
C. Increase his oral intake.
D. Place a heating pad on the abdomen.
Explanation: Gentle abdominal massage can stimulate peristalsis and help the irrigation solution drain completely from the colostomy. Reducing solution or using a heating pad is not standard, and increasing oral intake is unrelated.
Question 2 of 5.
An alert adult is being admitted for elective surgery. Which comment made by the client indicates a need for more instruction regarding advance directives?
A. I brought a copy of the completed form with me.
B. I am glad I don't have to make decisions about my care anymore.
C. My husband is the one who gets to make decisions for me.
D. My children all have copies of the living will.
Explanation: Advance directives allow clients to specify care preferences, not relinquish decision-making entirely. This comment suggests a misunderstanding that requires further education.
Question 3 of 5.
A mother calls the pediatrician's office stating that her 15-month-old son received an MMR vaccination yesterday. Today, the site of the injection is red, warm, and puffy. What is the best action for the nurse to take?
A. Report the symptoms to the physician as an adverse reaction
B. Suggest the mother apply a warm compress every two hours
C. Advise the mother to give her son baby aspirin
D. Explain to the mother that this is an expected response
Explanation: Mild redness, warmth, and swelling at the MMR injection site are expected reactions, resolving without intervention.
Question 4 of 5.
A 56-year-old client who had a complete hysterectomy 8 months ago is admitted for opiate detoxification. The second day after admission, the client complains of abdominal cramping and sweating. What is the nurse's best response?
A. Contact the gynecologist for details of the operation
B. Suspect drug seeking and suggest the client take a walk around the unit
C. Tell the client she is probably constipated and ask for an order for Milk of Magnesia
D. Explain to the client that her symptoms are an expected physical response to detoxification and offer comfort medications as ordered
Explanation: Abdominal cramping and sweating are withdrawal symptoms during opiate detoxification, requiring comfort measures and reassurance.
Question 5 of 5.
Immediately following a cardiac catheterization, the client asks to go to the toilet. What is the best response by the nurse?
A. Assist the client to the toilet
B. Show the client where the toilet is and allow him/her to walk there if stable
C. Assist the client to a bedside commode
D. Assist the client onto a bedpan
Explanation: Post-catheterization, bed rest is required to prevent bleeding at the insertion site; a bedpan maintains immobility.
Related Questions
A client with a diagnosis of HPV is at risk for which of the following?