NCLEX-RN ACTUAL EXAM TEST QUESTIONS &
ANSWERS LATEST UPDATE 2024
The nurse is instructing a client who has had an ileostomy
about the diet following surgery. The nurse should tell
the client:
"Limit your fluids to 1,000 mL/day."
"Chew your food thoroughly."
"There is no need to monitor your diet."
"Six small meals a day will prevent abdominal
distention." - ANSWER-The client is instructed to chew
food well to aid digestion and prevent obstruction.The
client should maintain an adequate fluid intake.The client
is usually placed on a regular diet but is encouraged to
eat high-fiber, high-cellulose foods (e.g., nuts, popcorn,
corn, peas, tomatoes) with caution; these foods may
swell in the intestine and cause an obstruction.Eating six
small meals a day is not necessary.
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,A client in the second stage of labor who planned an
unmedicated birth is in severe pain because the fetus is
in the ROP position. The nurse should place the client
in which position for pain relief?
lithotomy
right lateral
hands and knees
tailor sitting - ANSWER-Placing the client in the hands
and knees position pulls the fetal head away from
the sacral promontory (relieving pain) and facilitates
rotation of the fetus to the anterior position. Lithotomy is
the position preferred by some health care providers
(HCP) for delivery but does not facilitate rotation. The
right lateral position will perpetuate the ROP(right
occiput posterior: sunny side-up) position. Tailor sitting
facilitates descent in OA positions.
A client in a hospice program has increasing pain, and
the nurse is collaborating with the client to make a pain
management plan. Which plan will be most effective for
the client?
administering doses of analgesic when pain is a "5" on
Ask for various Exams or Study materials from
()
,a scale of 1 to 10.
providing enough analgesia to keep the client semi-
somnolent
Ask for various Exams or Study materials from
()
, allowing an analgesia-free period so that the client can
carry out daily hygienic activities.
administering pain medications over a 24-hour period -
ANSWER-The desired outcome for management of pain is
that the client's or family's subjective report of pain is
acceptable and documented using a pain scale; the goal
is that behavioral and physiologic indicators of pain are
absent around the clock. The nurse and client/family
should develop a systematic approach to pain
management using information gathered from history
and a hierarchy of pain measurement. Pain should be
assessed at frequent intervals. The client should not
wait to receive medication until the pain is midpoint
on the pain scale, nor should the client receive so much
pain medication that he or she is not alert. Continuous
pain relief is the goal, not just during particular
periods during the day.
A client with a history of posttraumatic stress is panting
and breathing heavily while shouting out some strange
words. The nurse reviews the nursing assessment and
understands that the client is practicing a form of
relaxation called power breathing.
Ask for various Exams or Study materials from
()
ANSWERS LATEST UPDATE 2024
The nurse is instructing a client who has had an ileostomy
about the diet following surgery. The nurse should tell
the client:
"Limit your fluids to 1,000 mL/day."
"Chew your food thoroughly."
"There is no need to monitor your diet."
"Six small meals a day will prevent abdominal
distention." - ANSWER-The client is instructed to chew
food well to aid digestion and prevent obstruction.The
client should maintain an adequate fluid intake.The client
is usually placed on a regular diet but is encouraged to
eat high-fiber, high-cellulose foods (e.g., nuts, popcorn,
corn, peas, tomatoes) with caution; these foods may
swell in the intestine and cause an obstruction.Eating six
small meals a day is not necessary.
Ask for various Exams or Study materials from
()
,A client in the second stage of labor who planned an
unmedicated birth is in severe pain because the fetus is
in the ROP position. The nurse should place the client
in which position for pain relief?
lithotomy
right lateral
hands and knees
tailor sitting - ANSWER-Placing the client in the hands
and knees position pulls the fetal head away from
the sacral promontory (relieving pain) and facilitates
rotation of the fetus to the anterior position. Lithotomy is
the position preferred by some health care providers
(HCP) for delivery but does not facilitate rotation. The
right lateral position will perpetuate the ROP(right
occiput posterior: sunny side-up) position. Tailor sitting
facilitates descent in OA positions.
A client in a hospice program has increasing pain, and
the nurse is collaborating with the client to make a pain
management plan. Which plan will be most effective for
the client?
administering doses of analgesic when pain is a "5" on
Ask for various Exams or Study materials from
()
,a scale of 1 to 10.
providing enough analgesia to keep the client semi-
somnolent
Ask for various Exams or Study materials from
()
, allowing an analgesia-free period so that the client can
carry out daily hygienic activities.
administering pain medications over a 24-hour period -
ANSWER-The desired outcome for management of pain is
that the client's or family's subjective report of pain is
acceptable and documented using a pain scale; the goal
is that behavioral and physiologic indicators of pain are
absent around the clock. The nurse and client/family
should develop a systematic approach to pain
management using information gathered from history
and a hierarchy of pain measurement. Pain should be
assessed at frequent intervals. The client should not
wait to receive medication until the pain is midpoint
on the pain scale, nor should the client receive so much
pain medication that he or she is not alert. Continuous
pain relief is the goal, not just during particular
periods during the day.
A client with a history of posttraumatic stress is panting
and breathing heavily while shouting out some strange
words. The nurse reviews the nursing assessment and
understands that the client is practicing a form of
relaxation called power breathing.
Ask for various Exams or Study materials from
()
