Fundamentals NCLEX RN Questions
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Question 1 of 5.
Extract:The nurse cares for a client in the outpatient surgical center who is scheduled for a cholecystectomy Item 1 of 1 Nurses' Note 0730 – The client arrives at the preoperative area with his family. He reports that he is anxious about the procedure. The pre-operative assessment was completed at this time. 20-gauge peripheral vascular access established in the right antecubital space. + blood return and flushes without resistance. The client reports no pain at the insertion site.
The nurse reviews the completed pre-operative assessment.Select the findings on the assessment that require follow-up
A. ID verified and band applied
B. The surgeon has not obtained informed consent
C. Client took his prescribed phenytoin with a sip of water this morning
D. The client reports his last meal and fluid intake was the previous day at 2200
E. The client stated he was going to drive himself home after the procedure
Explanation: Assessment items requiring follow-up include the informed consent not yet obtained by the surgeon. Before further preoperative activities may continue, the nurse must ensure this is completed to avoid unnecessary diagnostic testing and intervention. Additionally, the client will not be permitted to drive themselves home after this procedure because this involves general anesthesia. Activities requiring significant concentration, operation of heavy machinery, or driving are typically prohibited 24 hours following the initiation of general anesthesia. The other assessment findings do not require intervention. ID banding and verification are expected during the preoperative process. The client's ID will also be verified in the intraoperative and postoperative processes. Medications such as phenytoin can be taken with a sip of water to prevent seizure activity. The client has been NPO for approximately eight hours, sufficient time to prevent aspiration.
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.
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