Fundamentals NCLEX RN Questions
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Question 1 of 5.
Extract:The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis. Item 3 of 6 Current Medications Nurses' Notes • cephalexin 500 mg p.o. every six hours for 10 days • diazepam 5 mg p.o. daily PRN muscle spasm • multivitamin 1 tablet daily • ergocalciferol 10,000 international units p.o. Daily
The nurse updates the nursing note with an environmental assessment for a 67-year-old female client with progressive multiple sclerosis. The nurse should first address the client's
A. fatigue.
B. sensation in the extremities.
C. nutritional intake.
D. environmental hazards.
Explanation: Environmental hazards (e.g., furniture used for ambulation) pose an immediate fall risk, which is critical to address first for safety.
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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