NCLEX-RN QUESTION AND ANSWERS WITH RATIONALES 2023

NCLEX-RN QUESTION AND ANSWERS WITH RATIONALES 2023 Physiological Integrity: Basic Care & Comfort Practice Questions 1. As the registered nurse in the emergency department, you are taking care of an adolescent client who had just fractured their femur during gymnasium class at their high school. After casting, you will be discharging the client with crutches. Which of the following client goals that is paired with its learning domain should be included in the patient teaching plan for this client and the parents? A. Psychomotor domain: The client will slightly bend their elbows when holding the hand grips. B. Psychomotor domain: The client will rest their weight on the padded areas on the top of the crutches. C. Cognitive domain: The client will slightly bend their elbows when holding the hand grips. D. Cognitive domain: The nurse will tell the client how often the tips on the crutches must be replaced. Correct Response: A The client goal that is paired with its learning domain that should be included in the patient teaching plan for this client and the parents is “The client will slightly bend their elbows when holding the hand grips” which is part of the psychomotor domain and not the cognitive domain. Lastly, the “nurse will” is an intervention and not a client goal or expected outcome which should be learner, not nurse, oriented. 2. Which basic activity of daily living assistive device can be useful for the client who is affected with poor fine motor coordination? A. An aphasia aid B. A button hook C. Honey thickened liquids D. A word board Correct Response: B The basic activity of daily living assistive device can be useful for the client who is affected with poor fine motor coordination is a button hook that would be used for the dressing activity of daily living. An aphasia aid and a word board are assistive devices to facilitate communication when the client is affected with a communication deficit such as aphasia; and, lastly honey thickened liquids are indicated for clients with a swallowing disorder and they are not indicated for clients with poor fine motor coordination. 3. As the nurse in an ambulatory care area, you see a new client enter with a cane that appears too short for the client. What should you do? A. Place the client in a wheelchair to protect their safety in the clinic. B. Remove the cane from the client to protect their safety. C. Teach the client about the proper length of a cane. D. Have the client use a wheelchair rather than the cane. Correct Response: C You should teach the client about the proper length of a cane. The proper length of the cane should be the length that only permits the client’s elbow to be slightly flexed. Some canes like a wooden cane are not adjustable to the client’s height and others can be adjusted to meet the height needs of the client. You would not place the client in a wheelchair or ask the client to use a wheelchair and you would also not take the cane, which is their personal property, away from them. You would use this observation as a learning need assessment and, as such, you should teach the client about the proper length of a cane and help them to adjust the height of the cane if the client’s cane is a height adjustable one. 4. You are caring for a post-operative client who is complaining of abdominal distention and flatus. Which intervention would you most likely do for this client? A. A cleansing enema B. A retention enema C. A return-flow enema D. A laxative Correct Response: C The most likely intervention for this client, after getting a doctor’s order, is a return flow enema. Return-flow enemas, similar to a carminative enema, are used to relieve flatus and stimulate peristalsis which is frequently a problem after a client has received anesthesia. Cleansing enemas are used to relieve constipation; and a retention enema is used to administer a medication, to soften stool and to lubricate the rectum so that it is easier and more comfortable for the client to defecate. Finally, the data in this question does not indicate that the client is constipated and in need of a laxative. 5. Which of the following is a commonality that is shared in terms of both restraints and urinary catheters? A. Both can lead to infection. B. Both are invasive procedures. C. Both are considered sentinel. D. Both are the last resort. Correct Response: D The commonality that is shared in terms of both restraints and urinary catheters is that both are the last, not the first, treatment of choice. Both indwelling urinary catheters and restraints pose risks and complication; therefore, both of these interventions must be prevented with the use of preventive measures. Indwelling urinary catheters are invasive but restraints are not invasive; indwelling urinary catheters can lead to infection but restraints do not. Lastly, neither are sentinel. A sentinel event is an event or occurrence, incident or accident that has led to or may have possibly led to client harm. Even near misses, that have the potential for harm, are considered sentinel events because they have the potential to cause harm in the future. 6. Your incontinent client is incontinent of urine and stool. Which of the following products would you recommend for this client when cost is a major consideration in this decision? A. Any solid skin barrier B. A hydrocolloid solid skin barrier C. Hollister’s Flextend D. A skin sealant Correct Response: D You would recommend a skin sealant, including products like Bard’s Protective Barrier and Convatec’s Allkare, which are a fast drying polymer transparent film that can be applied relatively simply with a wipe or a spray. These products are easy to use and less expensive than solid skin barriers, including Hollister’s Flextend and others containing hydrocolloids. 7. You are planning discharge education for your client who has a new colostomy. Which complication of a colostomy should you educate this client about? A. A prolapsed stoma B. A vitamin B12 deficiency C. Nocturnal enuresis D. GI stone formation Correct Response: A Some of the complications associated with a colostomy include a prolapsed stoma, infection, dehiscence, an ischemic ileostomy, a peristomal hernia, stoma stenosis, stomal retraction, necrosis, mucocutaneous separation, stomal trauma, peristomal skin damage as the result of leakage and parastomal hernias. A vitamin B12 deficiency, nocturnal enuresis and urinary stone formations are complications associated with urinary diversion and not fecal ostomy diversions. 8. Select the hazard of immobility that is accurately paired with an appropriate expected outcome of care that the nurse provides to prevent this complication. A. Bone demineralization: Turning and positioning every 2 hours B. Urinary stasis: The client will consume 1,000 mL of oral fluids per day C. Muscle atrophy: The client will perform range of motion exercises at least 3 times a day D. Hypercalcemia: Maintaining fluid intake of 1,000 mL per day Correct Response: C “The client will perform range of motion exercises at least 3 times a day” is an appropriate expected outcome of care that the nurse provides to prevent this complication. Urinary stasis and hypercalcemia, both hazards of immobility, can be prevented when the client will consume 2,000 mL of oral fluids per day. Lastly, calcium loss from the bones can be prevented by weight bearing activity, and not turning and positioning in bed. 9. During you musculoskeletal assessment of the client, you determine that the client has muscular strength against gravity but not against resistance. You would document this assessment as: A. 1 on the scale of 1 to 3 B. 2 on the scale of 1 to 5 C. 3 on the scale of 0 to 5 D. 4 on the scale of 0 to 5 Correct Response: C You would document this client’s muscular strength as a 3 on a scale of 0 to 5. Muscular strength is classified on a scale of zero to five, as below.  Zero: No muscular contraction  One: No muscular movement, only a quiver is noted  Two: Muscular movement but only when assisted with gravity  Three: Muscular movement against gravity but not against resistance  Four: Muscular movement against resistance  Five: Full muscular movement and strength 10. You are working as a wound care nurse. You measure the size of a client’s wound and it is 3 cm deep, 2 cm long and 4 cm wide. You would document the dimension of this wound as: A. 6 cm B. 12 cm C. 20 cm D. 24 cm Correct Response: D You would document the size of this wound as 24 cm. After the wound is assessed and measured, the wound dimension is calculated by multiplying the length by the width by the depth of the wound. For example when the length of the sound is 3 cm deep, 2 cm long and 4 cm wide, it is calculated with 3 x 2 x 4 = 24 cm. 11. Your client had a ruptured appendix and peritonitis. What type of healing would be most likely for this client? A. Secondary intention healing B. Tertiary intention healing C. Primary prevention healing D. Secondary prevention healing Correct Response: A Secondary intention healing is the most likely type of wound healing for this client because of the risks associated with the deep infection associated with the ruptured appendix and the peritonitis. Secondary intention healing, also referred to as healing by second intention, is done for contaminated wounds in order to prevent infections, to prevent the formation of abscesses and to promote healing from the bottom up to the outer surface of the skin so that any potential infection is not closed in at the bottom of the wound. These open wounds are irrigated with a sterile solution and then packed to keep them open and, over time, they will heal on their own. The resulting scar is more obvious than those scars that result from primary intention healing. Primary intention healing is facilitated with wounds without infection. The wound edges are approximated and closed with a closure technique such as suturing, Steri Strips, and surgical glues. Tertiary intention healing, also referred to as healing by tertiary intention, is a combination of secondary and primary healing. Tertiary intention healing begins with several days of open wound irrigations and packing, which is secondary healing, followed by the closure of the wound edges with approximation and suturing which is primary healing. Some traumatic wounds are healed with tertiary intention. Primary, secondary and tertiary prevention strategies are prevention, interventions and restorative or rehabilitation care and not methods of wound healing