NCLEX-PN Test-Bank (200 Questions with Answers and Explanation

66. The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to: A. Take the blood pressure, pulse, and temperature B. Ask the client to rate his pain on a scale of 0–5 C. Watch the client’s facial expression D. Ask the client if he is in pain Answer B: The best way to evaluate pain levels is to ask the client to rate his pain on a scale. In answer A, the blood pressure, pulse, and temperature can alter for other reasons than pain. Answers C and D are not as effective in determining pain levels. 67. The nursing is participating in discharge teaching for the post-partal client. The nurse is aware that an effective means of managing discomfort associated with an episiotomy after discharge is: A. Promethazine B. Aspirin C. Sitz baths D. Ice packs Answer C: A sitz bath will help with swelling and improve healing. Ice packs, in answer D, can be used immediately after delivery. Answers A and B are not used in this instance. 68. Which of the following post-operative diets is most appropriate for the client who has had a hemorroidectomy? A. High-fiber B. Low-residue C. Bland D. Clear-liquid Answer D: After surgery, the client will be placed on a clear-liquid diet and progressed to a regular diet. Stool softeners will be included in the plan of care, to avoid constipation. Later, a high-fiber diet, in answer A, is encouraged, but this is not the first diet after surgery. Answers B and C are not diets for this type of surgery. 69. The physician has ordered a culture for the client with suspected gonorrhea. The nurse should obtain which type of culture? A. Blood B. Nasopharyngeal secretions C. Stool D. Genital secretions Answer D: A culture for gonorrhea is taken from the genital secretions. The culture is placed in a warm environment, where it can grow nisseria gonorrhea. Answers A, B, and C are incorrect because these cultures do not test for gonorrhea. 70. The nurse is caring for a client with cerebral palsy. The nurse should provide frequent rest periods because: A. Grimacing and writhing movements decrease with relaxation and rest. B. Hypoactive deep tendon reflexes become more active with rest. C. Stretch reflexes are increased with rest. D. Fine motor movements are improved. Answer A: Frequent rest periods help to relax tense muscles and preserve energy. Answers B, C, and D are incorrect because they are untrue statements. 71. The nurse is making assignments for the day. Which client should be assigned to the nursing assistant? A. A client with Alzheimer’s disease B. A client with pneumonia C. A client with appendicitis D. A client with thrombophebitis Answer A: The client with Alzheimer’s disease is the most stable of these clients and can be assigned to the nursing assistant, who can perform duties such as feeding and assisting the client with activities of daily living. The clients in answers B, C, and D are less stable and should be attended by a registered nurse.