NCLEX-RN
Safe and Effective Care Environment NCLEX RN Questions
1. What does the medical term 'diaphoresis' mean?
- A. Profuse vomiting
- B. Profuse sweating
- C. Gasping for air
- D. None of the above
Correct answer: B
Rationale: The correct answer is B: Profuse sweating. Diaphoresis is a medical term that refers to excessive sweating. It is commonly seen in emergency situations such as heart attacks or diabetic episodes. Choice A, 'Profuse vomiting,' is incorrect as diaphoresis is not related to vomiting. Choice C, 'Gasping for air,' is also incorrect as it refers to difficulty breathing, not sweating. Choice D, 'None of the above,' is incorrect as diaphoresis specifically relates to sweating.
2. 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.
3. When examining an older adult, which technique should the nurse use?
- A. Minimize touching the patient as much as possible.
- B. Attempt to perform the entire physical examination during one visit.
- C. Speak loudly and slowly due to potential hearing deficits in aging adults.
- D. Arrange the sequence of the examination to allow as few position changes as possible.
Correct answer: D
Rationale: When examining an older adult, it is crucial to arrange the sequence of the examination to minimize position changes. This helps prevent discomfort and fatigue for the older adult, who may have mobility issues. Option A is incorrect because physical touch is essential when examining older adults, as their other senses may be diminished. Option B is incorrect as it is better to break the examination into multiple visits to ensure thoroughness and comfort. Option C is incorrect because while some older adults may have hearing deficits, it is not appropriate to assume this for all individuals without proper assessment.
4. The client often sighs and says in a monotone voice, 'I'm never going to get over this.' When encouraged to participate in care, the client says, 'I don't have the energy.' These cues are suggestive of which nursing diagnoses? Select all that apply.
- A. Hopelessness
- B. Power
- C. Interrupted sleep pattern
- D. Disturbed self-esteem
Correct answer: A
Rationale: A nursing diagnosis involves clinical judgment about a response to a health problem. In this scenario, the client's expressions of feeling overwhelmed and lacking energy indicate feelings of hopelessness and powerlessness. While fatigue is mentioned, there is no direct evidence to support an interrupted sleep pattern, making option C incorrect. Similarly, disturbed self-esteem and self-care deficit are not evident from the given cues, making options D and E incorrect.
5. Which body plane divides the body into right and left sides?
- A. Frontal Plane
- B. Medial Plane
- C. Median Plane
- D. Transverse Plane
Correct answer: C
Rationale: The correct answer is the Median Plane, also known as the sagittal plane. It divides the body into right and left sides. The Frontal Plane, or coronal plane, divides the body into front and back sections. The Transverse Plane divides the body into superior (upper) and inferior (lower) sections. Therefore, choices A, B, and D are incorrect as they do not specifically divide the body into right and left sides.
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