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. What is the correct action regarding thigh pressure when comparing it to arm pressure in an adolescent with high blood pressure?
- A. The popliteal artery should be auscultated to obtain thigh pressure.
- B. The best position to measure thigh pressure is the prone position.
- C. If the blood pressure in the arm is high in an adolescent, then it should be compared with the thigh pressure.
- D. Thigh pressure is generally higher than arm pressure due to the proximity to the heart and the size of the popliteal vessels.
Correct answer: C
Rationale: When blood pressure measured in the arm is significantly elevated, especially in adolescents and young adults, it is crucial to compare it with thigh pressure to assess for coarctation of the aorta. The popliteal artery, not the femoral artery, should be auscultated for the thigh pressure reading as the femoral artery is closer to the placement of the blood pressure cuff. Generally, thigh pressure is higher than arm pressure; however, if there is coarctation of the artery, arm pressures can be higher than thigh pressures. The preferred position for measuring thigh pressure is the prone position, not supine, with the knee slightly bent to facilitate accurate readings.
3. Which of the following medical terms means 'surgical fixation of the stomach'?
- A. Abdominorrhaphy
- B. Gastroplasty
- C. Gastropexy
- D. Abdominorrhexis
Correct answer: C
Rationale: The correct answer is 'Gastropexy,' which means 'surgical fixation of the stomach.' This procedure involves surgically fixing the stomach in place. 'Abdominorrhaphy' refers to suturing or repairing the abdomen, not related to fixing the stomach. 'Gastroplasty' is a surgical reconstruction of the abdomen, not specifically related to fixing the stomach. 'Abdominorrhexis' refers to the rupture or tearing of the abdomen, not a surgical fixation procedure.
4. A client is taking a walk down the hallway when she suddenly realizes that she needs to use the restroom. Although she tries to make it to the bathroom on time, she is incontinent of urine before reaching the toilet. What type of incontinence does this situation represent?
- A. Relex incontinence
- B. Urge incontinence
- C. Total incontinence
- D. Functional incontinence
Correct answer: D
Rationale: Functional incontinence occurs when a client develops an urge to void but may not be able to reach the toilet in time. In this scenario, the client had the urge to use the restroom but was unable to make it in time, leading to incontinence. Functional incontinence may be related to conditions that cause the client to forget bladder sensation until the last minute, such as cognitive changes, or the client may have mobility problems that prevent her from reaching the bathroom in time. Choice A, Reflex incontinence, is incorrect as reflex incontinence is characterized by the involuntary loss of urine due to hyperreflexia of the detrusor muscle. Choice B, Urge incontinence, is not the correct answer as urge incontinence is the involuntary loss of urine associated with a strong desire to void. Choice C, Total incontinence, is also incorrect as it refers to the continuous and unpredictable loss of urine, not specifically related to the inability to reach the toilet in time.
5. A client with expressive aphasia is pointing wildly at the bath water but unable to speak. Which response from the nurse is most appropriate?
- A. Is something wrong with the bath water?
- B. Just calm down, we'll finish your bath soon.
- C. Are you trying to tell me something?
- D. Shall I turn on the television?
Correct answer: A
Rationale: A client with expressive aphasia faces difficulty expressing themselves verbally but can understand others. In this scenario, the client's gestures indicate a communication attempt. The nurse's best response is to directly address the potential issue the client is indicating, which is the bath water. Option A acknowledges the client's non-verbal communication and seeks to address their concern. Choices B, C, and D do not directly address the client's attempt to communicate about the bath water, which is the focal point of the interaction.
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