NCLEX NCLEX-RN
Psychosocial Integrity NCLEX RN Questions
1. The client prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct?
- A. Place the client in a high Fowler position.
- B. Assist the client in assuming a left side-lying position.
- C. Measure the tube from the tip of the nose to the xiphoid process.
- D. Assist the client in flexing the neck forward to facilitate tube insertion.
Correct answer: Place the client in a high Fowler position.
Rationale: The correct intervention during nasogastric tube insertion in an awake and alert client is to place them in a high Fowler position (A). Left side-lying position (B) is more suitable for unconscious or obtunded clients. When measuring the tube length, it should be from the tip of the nose to behind the ear, and then from behind the ear to the xiphoid process (C). Assisting the client in flexing the neck forward (D) is appropriate to facilitate tube insertion rather than extending the neck back, which may lead to complications. Proper positioning and measurements are crucial to prevent complications and ensure successful nasogastric tube placement.
2. The clinic nurse is obtaining data about a child with a diagnosis of lactose intolerance. Which data should the nurse expect to obtain on assessment?
- A. Reports of frothy stools and diarrhea
- B. Reports of foul-smelling ribbon stools
- C. Reports of profuse, watery diarrhea and vomiting
- D. Reports of diffuse abdominal pain unrelated to meals or activity
Correct answer: Reports of frothy stools and diarrhea
Rationale: Lactose intolerance commonly presents with frothy stools and diarrhea due to the inability to digest lactose. Other symptoms include abdominal distension, crampy abdominal pain, and excessive flatus. Foul-smelling ribbon stools are indicative of Hirschsprung's disease, not lactose intolerance. Profuse, watery diarrhea and vomiting are more characteristic of celiac disease. Diffuse abdominal pain unrelated to meals or activity is a typical symptom of irritable bowel syndrome, not lactose intolerance.
3. While caring for a patient with respiratory disease, the nurse observes that the patient's SpO2 drops from 93% to 88% while the patient is ambulating in the hallway. What is the priority action of the nurse?
- A. Notify the healthcare provider
- B. Document the response to exercise
- C. Administer the PRN supplemental O2
- D. Encourage the patient to pace activity
Correct answer: Administer the PRN supplemental O2
Rationale: The drop in SpO2 to 88% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising. Administering PRN supplemental oxygen is the priority action to correct the hypoxemia and ensure adequate oxygenation during activity. Notifying the healthcare provider can be done after stabilizing the patient's oxygen levels. Documenting the response to exercise is important but secondary to addressing the immediate hypoxemia. Encouraging the patient to pace activity is not sufficient to address the acute drop in SpO2 and provide the necessary oxygen support.
4. Which of the following clients is most likely ready to be dismissed from an inpatient care setting to home?
- A. A 65-year old male with urine output of 60cc in the past four hours
- B. A 2-month old female with a temperature of 100.6 rectally
- C. A 38-year old female who transitioned from IV TPN to full liquids six hours ago
- D. A 4-year old male with an oxygen saturation of 96% on room air
Correct answer: A 4-year old male with an oxygen saturation of 96% on room air
Rationale: Clients must meet a certain amount of set criteria before they will be discharged from a healthcare facility. Although guidelines may vary between locations, most healthcare facilities expect clients to have adequate oxygenation, nutrition, and elimination; and be free from fever, vomiting, and significant pain
5. An older adult patient brought to the emergency department by a family member is wandering outside, saying, “I can’t find my way home.” The patient is confused and unable to answer questions. What is the nurse’s best action?
- A. Document the patient’s mental status and obtain other assessment data from the family member.
- B. Record the patient’s answers to questions on the nursing assessment form.
- C. Ask an advanced practice nurse to perform the assessment interview.
- D. Call for a mental health advocate to maintain the patient’s rights.
Correct answer: A: Document the patient’s mental status and obtain other assessment data from the family member.
Rationale: In this scenario, the patient is confused and unable to answer questions. When the patient is unable to provide information, it is important to use secondary sources such as family members. The nurse's best action is to document the patient's mental status and obtain additional assessment data from the family member. This approach will help gather relevant information about the patient's condition. Asking an advanced practice nurse to perform the assessment interview is not necessary as it is within the staff nurse's scope of practice. Calling for a mental health advocate is also unnecessary at this point as the priority is to assess the patient's condition and gather information from the family member.
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