NCLEX RN Practice Test Free
Question 1 of 5.
The nurse is assisting a client with a colostomy irrigation. The client is positioned on the toilet and has removed the colostomy pouch, and the irrigation bag is filled with 1000 mL of warm water. Place the following actions (in Roman numerals) in the correct order from first to last
- A. Allow 15 to 20 minutes for evacuation and then fold the sleeve, secure it, and leave it in place for 30 to 45 minutes before removing it.
- B. Allow the solution to flow in for 5 to 10 minutes and then clamp the tubing and close the top of the irrigation sleeve.
- C. Apply gloves, lubricate the cone tip, and insert it into the stoma, holding it securely.
- D. Apply the irrigation sleeve over the stoma.
- E. Hang the irrigation solution with the bottom of the bag being 20 inches above the stoma.
- E. Hang the irrigation solution with the bottom of the bag being 20 inches above the stoma.
- D. Apply the irrigation sleeve over the stoma.
- C. Apply gloves, lubricate the cone tip, and insert it into the stoma, holding it securely.
- B. Allow the solution to flow in for 5 to 10 minutes and then clamp the tubing and close the top of the irrigation sleeve.
- A. Allow 15 to 20 minutes for evacuation and then fold the sleeve, secure it, and leave it in place for 30 to 45 minutes before removing it.
Correct arrangement
Explanation: The correct order is: Hang the irrigation solution (V), apply the irrigation sleeve (IV), insert the cone tip (III), allow solution to flow (II), and allow evacuation (I), ensuring proper setup and procedure.
Question 2 of 5.
The home health care nurse is caring for a 30-year-old woman with type I diabetes mellitus. The client has been maintained on a regimen of NPH and regular insulin and a 1,800-calorie diabetic diet with normal blood sugar levels. Morning self-monitoring blood sugar (SMBG) readings the past two days were 205 mg/dL and 233 mg/dL. The nurse expects the physician to
A. reduce the client’s diet to 1,500 calorie ADA.
B. order 3 additional units of NPH insulin at 10 PM.
C. order an additional 10 units of regular insulin at 8 PM.
D. eliminate the client’s bedtime snack.
Explanation: dawn phenomena, treatment is to adjust evening diet, bedtime snack, insulin dose, and exercise to prevent early morning hyperglycemia
Question 3 of 5.
The nurse should explain to a client that tolbutamide (Orinase) is effective for diabetics who
A. can no longer produce any insulin.
B. produce minimal amounts of insulin.
C. are unable to administer their injections.
D. have a sustained decreased blood glucose.
Explanation: oral hypoglycemic agents are administered to type II (non-insulindependent) clients who are able to produce minimal amounts of insulin
Question 4 of 5.
Which of the following observations best indicates to the nurse that a paraplegic client can adequately carry out activities of daily living at home after discharge?
A. The client can shave himself and brush his teeth.
B. The client can transfer himself into and out of his wheelchair.
C. The client can maneuver his wheelchair without difficulty.
D. The client can prepare his own well-balanced meals.
Explanation: essential if client is to perform ADLs
Question 5 of 5.
A client in the ICU is given procainamide HCl (Pronestyl) slowly IV push. The nurse should withhold the next dose of this medication and notify the physician if which of the following is observed on the cardiac monitor?
A. One premature ventricular contraction (PVC).
B. Sinus rhythm with occasional bigeminy.
C. Persistent tachycardia of 112 beats per minute.
D. Prolongation of the QT interval.
Explanation: prolongation of the QT interval is a side effect that can lead to torsades de pointes, a life-threatening arrhythmia
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