NCLEX-RN
NCLEX RN Exam Prep
1. A client is preparing to irrigate a colostomy. Which of the following situations is a contraindication for this type of irrigation?
- A. The client has an incontinent ostomy
- B. The client has an irregular bowel routine
- C. The client has diverticulitis
- D. The colostomy bag contains fecal material
Correct answer: C
Rationale: When a client with a colostomy is preparing for irrigation, it is essential to consider contraindications that could pose risks or worsen the client's condition. Diverticulitis is a contraindication for colostomy irrigation because the inflamed diverticula could be further irritated by the flushing action during irrigation, potentially leading to complications. An incontinent ostomy, irregular bowel routine, or presence of fecal material in the colostomy bag are not specific contraindications for irrigation and can be managed through appropriate techniques and interventions.
2. Which theory reflects the view that illness is caused by an imbalance or disharmony in the forces of nature?
- A. Germ theory
- B. Naturalistic theory
- C. Magicoreligious theory
- D. Biomedical or scientific theory
Correct answer: B
Rationale: The naturalistic theory posits that illness results from an imbalance or disharmony in the forces of nature. According to this theory, maintaining a natural balance or harmony is essential to prevent illness. Conversely, germ theory and biomedical or scientific theory attribute illness to microorganisms, while magicoreligious theory attributes illness to supernatural forces such as deities or spirits. Therefore, the most appropriate theory reflecting the belief that illness arises from a disruption in natural forces is the naturalistic theory.
3. What is the purpose of MSDS sheets?
- A. Contain the ordering information for each piece of equipment in the office.
- B. Are required by OSHA to be accessible to all employees of the office.
- C. Can be used to treat patients who have been injured in equipment accidents.
- D. None of the above.
Correct answer: B
Rationale: MSDS sheets, also known as Materials Safety Data Sheets, are essential documents that provide detailed information about chemicals used in the workplace. They are required by OSHA to be easily accessible to all employees to ensure they have the necessary information to handle chemicals safely. MSDS sheets do not contain ordering information for equipment in the office (Choice A) or serve as a treatment guide for injured patients (Choice C). Therefore, the correct answer is that MSDS sheets are required by OSHA to be accessible to all employees of the office.
4. In which of the following ways can a nurse promote sleep for a client experiencing insomnia?
- A. Assist the client in using the bathroom one hour after going to bed
- B. Give the client a massage before bedtime
- C. Tuck bed sheets and blankets tightly around the client once settled in bed
- D. Give the client a pair of socks to wear if their feet become cold
Correct answer: D
Rationale: A nurse can promote sleep for a client experiencing insomnia by addressing factors that may hinder sleep. Cold feet can disrupt sleep, so providing the client with socks to keep their feet warm can enhance comfort and aid in promoting sleep. The correct answer focuses on a direct intervention to address a specific issue that can impact sleep quality. Choices A, B, and C do not directly address the issue of cold feet, which is a common problem that can interfere with sleep in individuals with insomnia. Assisting the client to use the bathroom, giving a massage in the morning, or tucking in bed sheets tightly do not target the discomfort caused by cold feet, making them less effective interventions for promoting sleep in this scenario.
5. A client is being assisted to lie in the Sims' position. In what position does the nurse arrange the client?
- A. The client lies on his side with the upper leg flexed
- B. The client lies on his back with his head lower than his feet
- C. The client lies on his abdomen with a pillow supporting his head
- D. The client is sitting up at a 90-degree angle
Correct answer: A
Rationale: The Sims' position is a side-lying position used for examinations or comfort. In the Sims' position, the client lies on their side with the upper leg flexed. The abdomen is slightly downward, and the lower arm is positioned behind the body. A pillow can be used to support the leg. Choice B is incorrect as it describes a position with the client lying on their back with the head lower than the feet. Choice C is incorrect as it describes a prone position, not the Sims' position. Choice D is incorrect as it describes a sitting position, not the Sims' position.
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