Fundamentals NCLEX RN Questions
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Question 1 of 5.
Extract:The nurse is removing an indwelling urinary catheter Item 1 of 1 Nurses Note The removal of the client's indwelling urinary catheter was attempted. Perineal hygiene was performed before the removal. The urine collection bag was emptied with 450 mL of clear, straw-colored urine. 2 mL of fluid was removed during the deflation of the balloon. Resistance was felt when the tubing was removed, and the client reported discomfort.
Drag words from the choices below to fill the blank in the following sentence. Prior to attempting to remove the catheter again, the nurse should--------------------------
- A. place a warm compress over the perineum
- B. cut the balloon inflation valve
- C. position the client at 45 degrees
- D. further deflate the catheter balloon
- D. further deflate the catheter balloon
Correct arrangement
Explanation: The amount of fluid removed from the balloon (this secures the catheter in place inside of the bladder) was inadequate. 10 mL of fluid is typically used to inflate the catheter balloon to keep it secure inside the bladder. The nurse should further deflate the catheter balloon by passively allowing the fluid to fill the syringe. The nurse may gently pull back on the syringe plunger if this does not work. By removing the residual volume, the nurse should then remove the catheter. Cutting the balloon inflation valve would negate the closed system. Cutting the valve is not standard practice and should not be done. Positioning the client 45 degrees is not appropriate for discontinuing an indwelling urinary catheter. The correct approach for positioning a client to remove an indwelling catheter is having a male client supine and a female in the dorsal recumbent position. Placing a warm compress over the perineum may give the client comfort, but this will not effectively troubleshoot the problem with the catheter. The issue is not with a bladder spasm, yet an indwelling urinary catheter that has not been entirely deflated.
Question 2 of 5.
Which of the following responses should the nurse avoid when communicating with a client who has just received a poor prognosis? Select all that apply.
A. My mother has the same thing.
B. I'll sit with you for a while.
C. I think you should try having surgery.
D. Don't cry, everything is going to be okay.
E. Do you have any questions for me right now?
Explanation: Avoid personal anecdotes, medical advice, or minimizing emotions, as they dismiss the client's feelings. Offering presence and open-ended questions are therapeutic.
Question 3 of 5.
The nurse is ambulating a client who is wearing a gait belt. The client begins to fall. The nurse should take which appropriate action to minimize injury?
A. Hold the gait belt, extend one leg, let the client slide against the leg, and lower the client to the floor.
B. Let go of the gait belt, grab the client under each arm, and gently lower the client to the floor.
C. Grasp the gait belt, and instruct the client to fall gently down to the floor in a side-lying position.
D. Hold the gait belt, and lower the client to the floor by using a narrow base of support.
Explanation: Using the gait belt to guide the client against the nurse's leg minimizes injury. Letting go, instructing a side-lying fall, or using a narrow base increases risk.
Question 4 of 5.
The nurse is teaching a client about a vegan diet. Which of the following foods should the nurse recommend for this diet? Select all that apply.
A. Legumes
B. Tofu
C. Almonds
D. Prunes
E. Baked fish
F. Grapefruit
Explanation: Vegan diets exclude animal products, so legumes, tofu, almonds, prunes, and grapefruit are suitable. Baked fish is not vegan.
Question 5 of 5.
Which of the following clients would most likely benefit from contralateral stimulation as a nonpharmacological comfort intervention to decrease pain?
A. A 36-year-old client with abdominal pain
B. A 56-year-old client with a below-the-knee amputation and phantom limb pain
C. A 76-year-old client with terminal cancer
D. An 84-year-old client with severe arthritis
Explanation: Contralateral stimulation, rubbing the opposite limb, is effective for phantom limb pain by altering pain perception. It is less effective for visceral, cancer, or arthritic pain.