NCLEX-RN
NCLEX RN Exam Prep
1. A client is about to have a TENS unit attached for pain relief. Which of the following actions is most appropriate in this situation?
- A. Inform the client that he may experience tingling sensations.
- B. Connect the TENS unit before the client goes to bed for the night.
- C. Inform the client that the TENS unit may have pain-reducing effects for 10 to 15 days.
- D. After treatment, inform the client that he may not use a TENS unit again for at least 2 weeks.
Correct answer: A
Rationale: When attaching a TENS unit for pain relief, it is essential to inform the client that he may experience tingling sensations. This is a common sensation experienced when using a TENS unit, but it should not cause muscle twitching. The therapeutic effects of a TENS unit usually last between 3 to 5 days. Choice B is incorrect because there is no specific recommendation to connect the TENS unit before bedtime. Choice C is incorrect as stating that the TENS unit may have pain-reducing effects for 10 to 15 days is inaccurate, as the effects typically last 3 to 5 days. Choice D is incorrect because there is no guideline suggesting that the client cannot use a TENS unit again for at least 2 weeks after treatment.
2. To which of the following do the CDC Standard precautions recommendations apply?
- A. Patients with diagnosed infections only
- B. Blood or body fluids with visible blood only
- C. All body fluids including sweat
- D. All patients receiving care in hospitals
Correct answer: D
Rationale: The correct answer is 'All patients receiving care in hospitals.' Standard precautions apply to all patients in healthcare settings, regardless of their infection status. These recommendations include all body fluids except sweat, non-intact skin, and mucous membranes. Choice A is incorrect as standard precautions are not limited to patients with diagnosed infections. Choice B is incorrect as standard precautions extend beyond blood or body fluids with visible blood. Choice C is incorrect as sweat is an exception to the body fluids covered under standard precautions.
3. What does an individual who believes in the magicoreligious theory of illness and disease think is the cause of illness?
- A. Germs and viruses
- B. Supernatural forces
- C. Eating imbalanced (hot/cold) foods
- D. Imbalance within his or her spiritual nature
Correct answer: B
Rationale: Individuals who adhere to the magicoreligious theory of illness and disease attribute the cause of illness to supernatural forces. In this perspective, the world is perceived as governed by supernatural forces that influence the well-being of individuals. The belief is that these forces can bring about both good and evil outcomes. Choices A, C, and D are incorrect. Germs and viruses are associated with the biomedical theory of illness. Eating imbalanced hot or cold foods is linked to the yin/yang naturalist theory. Imbalance within one's spiritual nature is not a recognized cause of illness in any of the established theories of illness.
4. While caring for Mrs. Thomas, you see a notation on the nursing care plan that states 'ambulate at least 10 yards qid'. This patient will be assisted with ambulation at which of the following times?
- A. 10:00 AM
- B. 10 am and 2 pm
- C. 10 am and 2 pm
- D. 10 am, 2 pm, 6 pm, and 10 pm
Correct answer: D
Rationale: The correct answer is to assist the patient with ambulation at 10 am, 2 pm, 6 pm, and 10 pm as qid stands for four times per day. This schedule is commonly followed in healthcare facilities to ensure regular ambulation and exercise for the patient. Choices A, B, and C do not cover all the specified times for ambulation as indicated by the qid notation on the care plan.
5. The client reports nausea and constipation. Which of the following would be the priority nursing action?
- A. Collect a stool sample
- B. Complete an abdominal assessment
- C. Administer an anti-nausea medication
- D. Notify the physician
Correct answer: B
Rationale: The priority nursing action when a client reports symptoms like nausea and constipation is to complete an abdominal assessment. Assessment is crucial as it involves the systematic collection of data to understand the client's condition. By assessing the abdomen, the nurse can gather essential information to make a nursing diagnosis and develop a care plan. Collecting a stool sample (Choice A) may be necessary but comes after the assessment to confirm findings. Administering an anti-nausea medication (Choice C) addresses symptoms but does not address the underlying cause without a thorough assessment. Notifying the physician (Choice D) should come after the assessment to provide a complete picture of the client's condition.
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