The nurse is preparing to administer an enema to a client who is exper

Fundamentals NCLEX RN Questions

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Question 1 of 5.

The nurse is preparing to administer an enema to a client who is experiencing constipation. Place the following actions in the order listed:

A. Lubricate the tip of the enema applicator
B. Remove the applicator after the solution has been infused.
C. Explain the procedure and help the client lie on the left side with their knees flexed and back toward you
D. Release clamp
E. Insert into the client's rectum
F. Fill the enema bag, prime, and clamp tubing

Correct arrangement

F. Fill the enema bag, prime, and clamp tubing
A. Lubricate the tip of the enema applicator
C. Explain the procedure and help the client lie on the left side with their knees flexed and back toward you
E. Insert into the client's rectum
D. Release clamp
B. Remove the applicator after the solution has been infused.

Explanation: The correct order is: fill and prime bag (F), explain and position client (C), lubricate tip (A), insert tube (E), release clamp (D), remove applicator (B). This ensures safe administration.

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.