NCLEX-RN ACTUAL EXAM TEST QUESTIONS & ANSWERS

NCLEX-RN ACTUAL EXAM TEST QUESTIONS & ANSWERS 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. 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 a scale of 1 to 10. providing enough analgesia to keep the client semi-somnolent 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. The best action for the nurse to take is to: monitor the client for respiratory difficulties. contact the health care provider for a psychiatric consult. allow privacy, but check on the client frequently. arrange for a sitter so the client is not left alone. - ANSWER-The nurse should acknowledge that the client is performing self-care for anxiety symptoms. The most respectful action is to allow privacy but to check on the client frequently. The client is likely chanting or reciting a mantra. There is no indication that the client is experiencing respiratory conflict. The client does not need a sitter or a psychiatric consult. Which action should be included in the nursing care for a client with cervical cancer who has an internal radium implant in place? Offer the bedpan every 2 hours. Provide perineal care twice daily. Check the position of the applicator hourly. Offer a low-residue diet. - ANSWER-Bowel movements can be difficult with the radium applicator in place. The purpose of the low-residue diet is to decrease bowel movements. The bowel is cleaned before therapy, and the woman is maintained on a lowresidue diet during treatment to prevent bowel distention and defecation. To prevent dislodgment of the applicator, the client is maintained on strict bed rest and allowed only to turn from side to side. Perineal care is omitted during radium implant therapy, although any vaginal discharge should be reported to the health care provider (HCP). It is rare for the applicator to extrude, so this does not need to be checked every hour. A breastfeeding mother who is experiencing breast engorgement asks the nurse if there is anything she can do to get relief. What is the best intervention for the nurse to implement? applying ice applying a breast binder teaching how to express the breasts administering bromocriptine - ANSWER-Teaching the client how to express her breasts will facilitate let-down, and provide temporary relief. Ice can promote comfort by decreasing blood flow, numbing, and discouraging further let-down of milk. It is not recommended because it also causes the rebound reaction of more let-down once the ice is removed. Breast binders are not effective in relieving the discomforts of engorgement. Bromocriptine is no longer recommended for lactation suppression.