NCLEX RN Fundamental Questions
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Question 1 of 5.
Extract:Item 1 of 1 • Assessment Neurological: Alert and Oriented x 4; anxious affect Cardiovascular: S1, S2 heart tones; all peripheral pulses palpable; no edema Gastrointestinal: Distended abdomen; absent bowel sounds; hiccups; reports persistent nausea Genitourinary: Denies dysuria; voiding every 3-4 hours with straw-colored urine Musculoskeletal: Full range of motion in all extremities; steady gait Integumentary: Incision is approximated; moderate dry sanguineous drainage was noted on the dressing. Pain: Reports incision pain as a 3 based on a scale of 0-10. • Vital Signs Blood Pressure 119/75 mm Hg Temperature 99° F (37° C) Heart rate 90/min Respiratory rate 17 breaths per minute Oxygen saturation 97% on room air
The nurse is caring for a client two days postoperative following a partial colectomy.Complete the sentence below from the list of options: The client is at risk of developing --------------based on the client's------------------------
- A. paralytic ileus
- B. wound infection
- C. intractable pain
- D. integumentary assessment
- E. pain assessment
- F. gastrointestinal assessment
- A. paralytic ileus
- F. gastrointestinal assessment
Correct arrangement
Explanation: The client exhibits signs of paralytic ileus, as evidenced by the gastrointestinal assessment findings (distended abdomen, absent bowel sounds, nausea, and hiccups). The clinical data do not support wound infection as it is too early in the postoperative period for this to occur, and the client has no other manifestations supporting this finding. Pain is expected in the postoperative period, and the current pain rating is mild-to-moderate (3). In contrast, intractable pain would be suggested by pain not relieved by medication and at a severe level.
Question 2 of 5.
The nurse is assisting a client with the use of a fracture bedpan. Which action should the nurse take?
A. Position the client prone while placing the bedpan.
B. Raise the head of the bed to 30 degrees.
C. Place the open rim of the bedpan toward the head of the bed.
D. Lower all of the side rails
Explanation: Raising the head of the bed to 30 degrees facilitates client comfort and proper positioning for a fracture bedpan. Prone positioning is incorrect, the open rim faces the foot of the bed, and lowering all side rails is unsafe.
Question 3 of 5.
Following scheduled radioactive iodine therapy in a nuclear medicine department, a nurse is speaking with a client following the client's ingestion of radioactive iodine regarding strategies to avoid radiating the client's family members. The nurse recognizes the need for additional client teaching when the client states:
A. I understand the need to avoid sharing food or utensils with others.
B. My children will miss my hugs and kisses for the next week.
C. I'll travel for a couple of weeks to prevent my family from receiving radiation from me.
D. I understand the need to flush the toilet with the lid closed two to three times after each use.
Explanation: Traveling for weeks is excessive and unnecessary. Avoiding shared items, limiting close contact, and double flushing are appropriate to reduce radiation exposure.
Question 4 of 5.
The nurse is teaching a client how to ambulate using crutches. Which of the following information should the nurse include?
A. Keep the crutches 4 in (10 cm) in front of your feet while standing.
B. When ascending stairs, lead with your unaffected (stronger) leg.
C. Before sitting down in a chair, move both crutches to the unaffected (stronger) side of the body.
D. Your shoulders should support your body weight while ambulating with crutches.
Explanation: Leading with the stronger leg when ascending stairs ensures stability. Crutches should be 6-10 inches forward, crutches stay in both hands when sitting, and weight is on hands, not shoulders.
Question 5 of 5.
The nurse is caring for a client with an indwelling urinary catheter connected to a drainage bag. The nurse demonstrates effective care when. Select all that apply.
A. Emptying the drainage bag when it is half full.
B. Collecting a urine specimen for culture from the port in drainage tubing.
C. Clamping the urinary catheter tubing prior to discontinuation.
D. Instructing the client to carry the collection bag above their bladder during ambulation.
E. The tubing goes in and out of the urethra during cleaning.
Explanation: Emptying when half full prevents reflux, and collecting from the port ensures sterility. Clamping is unnecessary, carrying above the bladder risks reflux, and tubing movement risks infection.
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