NCLEX-RN
NCLEX RN Exam Prep
1. Which of the following is part of client teaching regarding antiembolism stockings?
- A. Instruct the client to roll the top portion of the stocking down if it is too long
- B. Stockings are applied with the toes uncovered at the end
- C. Measure for thigh-high stockings from the foot to the knee
- D. Stockings are to be smooth from end to end without wrinkles
Correct answer: D
Rationale: When educating clients about antiembolism stockings, it is essential to emphasize that the stockings should be smooth from end to end without wrinkles. Wrinkles in the stockings can impede circulation, defeating the purpose of wearing them to prevent blood clot formation. Instructing the client to roll the top portion of the stocking down if it is too long (Choice A) is incorrect as it can create unnecessary pressure points. Stockings should be applied with the toes covered at the end (Choice B) to ensure proper compression. Measuring for thigh-high stockings should be done from the knee to the foot (Choice C) to ensure the correct fit and compression gradient.
2. While caring for Mr. Charles Y., you see a notation on the nursing care plan that states, 'remind the patient to use the incentive spirometer tid.' This patient will be reminded at which of the following times?
- A. 10:00 AM
- B. 10 am and 2 pm
- C. 10 am, 2 pm, and 6 pm
- D. 10 am, 2 pm, 6 pm, and 10 pm
Correct answer: C
Rationale: The abbreviation 'tid' stands for 'ter in die,' which means three times a day. In this case, the patient should be reminded to use the incentive spirometer at 10 am, 2 pm, and 6 pm. Option A, '10 am,' is too infrequent for tid dosing. Option B, '10 am and 2 pm,' is missing the third reminder at 6 pm. Option D, '10 am, 2 pm, 6 pm, and 10 pm,' includes an additional time that is not part of the standard tid dosing schedule.
3. Nursing care plans are _______________?
- A. written by CNAs before they provide care
- B. guidelines of care that all nursing team members use
- C. used by nurses but not by nursing assistants
- D. used by nursing assistants but not by nurses
Correct answer: B
Rationale: Nursing care plans are comprehensive documents created by registered nurses to outline individualized care for patients. These plans serve as guidelines for all members of the nursing team, including nursing assistants, to ensure consistent and quality care. Choice A is incorrect as CNAs typically assist in implementing the care plan rather than creating it. Choice C is incorrect as nursing care plans are utilized by all members of the nursing team, not exclusive to only nurses. Choice D is incorrect as nursing assistants also utilize nursing care plans to provide patient care effectively.
4. Which nursing intervention is most appropriate to reduce environmental stimuli that may cause discomfort for a client?
- A. Loosen pressure dressings on wounds
- B. Use assistance to lift a client in bed
- C. Check temperature of water used in a sponge bath
- D. Position the client in a prone position
Correct answer: C
Rationale: To reduce environmental stimuli that may cause discomfort for a client, nurses can implement various interventions. Checking the temperature of the water used in a sponge bath is crucial to prevent burns from water that is too hot or discomfort from water that is too cold. This intervention addresses a common source of discomfort for clients during personal care. Loosening pressure dressings on wounds, although important for wound care, does not directly address environmental stimuli. Using assistance to lift a client in bed is about proper positioning and preventing injury rather than reducing environmental stimuli. Positioning the client prone is not a suitable intervention for reducing discomfort caused by environmental stimuli.
5. A client is complaining of pain that starts in the shoulder and travels down the length of his arm. This type of pain is referred to as:
- A. Referred pain
- B. Superficial pain
- C. Radiating pain
- D. Precipitating pain
Correct answer: C
Rationale: Radiating pain is the correct term for pain that originates in one part of the body and extends to other related areas. In this scenario, the pain starting in the shoulder and traveling down the arm describes radiating pain. Referred pain (Choice A) is pain felt at a site different from the actual origin of the pain. Superficial pain (Choice B) is pain that arises from the skin or tissues just beneath it. Precipitating pain (Choice D) refers to pain that is triggered by specific actions or events, not the characteristic described in the question.
Similar Questions
Access More Features
NCLEX RN Basic
$69.99/ 30 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access @ $69.99
NCLEX RN Premium
$149.99/ 90 days
- 5,000 Questions with answers
- Comprehensive NCLEX coverage
- 30 days access @ $149.99