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. A 6-month-old infant has been brought to the well-child clinic for a checkup. The infant is currently sleeping. What would the nurse do first when beginning the examination?
- A. Wake the infant before beginning the examination.
- B. Examine the infant's hips before the infant wakes up.
- C. Auscultate the lungs and heart while the infant is still sleeping.
- D. Begin with the assessment of the eye and continue with the remainder of the examination in a head-to-toe approach.
Correct answer: C
Rationale: When the infant is quiet or sleeping, it is an ideal time to assess the cardiac, respiratory, and abdominal systems. It is recommended not to wake the infant unnecessarily. Auscultating the lungs and heart while the infant is still sleeping allows for a comprehensive assessment without disturbing the infant. Examining the infant's hips prematurely may disrupt the infant's sleep. Starting with an assessment of the eye is not appropriate as it is an invasive procedure and should be performed towards the end of the examination after the non-invasive assessments have been completed.
3. A patient is in the office for a cyst removal and is very anxious about the procedure. Which of the following descriptions of his respirations would be expected?
- A. Bradypnea
- B. Orthopnea
- C. Tachypnea
- D. Dyspnea
Correct answer: C
Rationale: Tachypnea is defined as a rapid, quick, and shallow respiration rate. When a patient is anxious, they may hyperventilate, leading to tachypnea. Bradypnea (Choice A) is slow breathing, which is not expected in an anxious patient. Orthopnea (Choice B) is difficulty breathing while lying down and is not directly related to anxiety. Dyspnea (Choice D) is shortness of breath, which may not be the primary respiratory pattern seen in an anxious patient undergoing a procedure. Therefore, the correct choice is tachypnea as it aligns with the expected respiratory response to anxiety.
4. Which of the following signs or symptoms indicates a possible nutritional deficiency?
- A. Subcutaneous fat at the waist and abdomen
- B. Presence of papillae on the surface of the tongue
- C. Straight arms and legs
- D. Pale conjunctiva
Correct answer: D
Rationale: A client with poor nutritional intake may have pale mucous membranes surrounding the eye, or the conjunctiva. This area should normally be pink, indicating good circulation and a lack of irritation or dryness. Improper nutrition can manifest as numerous signs in the body, including bowed legs, pale mucous membranes, a smooth or beefy tongue, and poor muscle tone. Subcutaneous fat at the waist and abdomen is not a sign of nutritional deficiency but rather of excess fat deposition. The presence of papillae on the surface of the tongue is normal and not indicative of a nutritional deficiency. Straight arms and legs are also typical anatomical features and not specifically related to nutritional deficiencies.
5. After a symptom is recognized, the first effort at treatment is often self-treatment. Which of the following statements is true about self-treatment?
- A. "Not recognized as valuable by most health care providers."?
- B. "Usually ineffective and may delay more effective treatment."?
- C. "Always less expensive than biomedical alternatives."?
- D. "Influenced by the accessibility of over-the-counter medicines."?
Correct answer: D
Rationale: After a symptom is identified, the first effort at treatment is often self-treatment. The availability of over-the-counter medications, the relatively high literacy level of Americans, and the influence of the internet and mass media in communicating health-related information to the general population have contributed to the high percentage of cases of self-treatment. Health care providers are recognizing the value of a wide variety of alternative, complementary, and traditional interventions. Many self-treatments, such as over-the-counter medications, are effective. Self-treatment is not always less expensive. Choice A is incorrect as health care providers are recognizing the value of self-treatment. Choice B is incorrect because self-treatment can be effective in many cases. Choice C is incorrect as self-treatment is not always less expensive; it depends on the specific treatment being used.
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