NCLEX-RN
NCLEX RN Exam Prep
1. A client is undergoing range of motion exercises, and the nurse moves the leg in a pattern of circumduction. Which movement is the nurse performing?
- A. Bending the leg at the knee
- B. Turning the foot inward and outward
- C. Moving the leg in a circle
- D. Moving the leg forward and up
Correct answer: C
Rationale: Circumduction involves moving a limb in a circular pattern. In this scenario, the nurse is performing circumduction by moving the leg in a circular motion, engaging the muscles of the gluteus maximus and gluteus medius. Choice A, 'Bending the leg at the knee,' is incorrect as it describes flexion and extension movements. Choice B, 'Turning the foot inward and outward,' refers to inversion and eversion movements of the foot, not circumduction. Choice D, 'Moving the leg forward and up,' describes flexion and abduction movements, not circumduction.
2. A nurse is preparing to insert a small-bore nasogastric feeding tube for a client's enteral feedings. In which method does the nurse measure the correct length of the tube?
- A. From the tip of the nose to the xiphoid process
- B. From the tip of the nose to the earlobe to the xiphoid process
- C. From the earlobe to the xiphoid process
- D. From the tip of the nose to the earlobe to the umbilicus
Correct answer: B
Rationale: When preparing to insert a nasogastric tube, the nurse must measure the correct length to ensure that the end of the tube will be in the correct position in the stomach. The accurate method to measure the length is from the tip of the nose to the earlobe to the xiphoid process. This length ensures that the end of the tube reaches the stomach, avoiding placement in the small intestine or esophagus. Choice A is incorrect as it does not include the earlobe, which is essential for accurate measurement. Choice C is incorrect because measuring from the earlobe alone does not provide the correct length for positioning in the stomach. Choice D is incorrect as it includes the umbilicus, which is not the appropriate landmark for measuring the length of a nasogastric tube intended for stomach placement.
3. Which of the following is NOT an acceptable abbreviation?
- A. D/C
- B. tid
- C. bid
- D. qid
Correct answer: A
Rationale: The correct answer is A: D/C. D/C is not an acceptable abbreviation as it can be easily confused with both 'discharge' and 'discontinue.' The abbreviations 'tid' (three times a day), 'bid' (twice a day), and 'qid' (four times a day) are commonly used in medical contexts to indicate dosing frequencies and are widely accepted in healthcare settings.
4. Which of the following is a disadvantage of using a dry heat application?
- A. Dry heat is more likely to cause burns than moist heat
- B. Dry heat does not penetrate deeply into the tissues
- C. Dry heat causes the skin to dry out more quickly
- D. Dry heat can quickly cause skin breakdown
Correct answer: C
Rationale: The correct answer is that dry heat causes the skin to dry out more quickly. When comparing dry and moist heat applications, dry heat is less likely to cause burns and skin breakdown. However, one of the disadvantages of dry heat is that it does not penetrate deeply into the tissues and may lead to faster drying out of the skin. This can have negative effects on skin integrity and overall comfort during therapy. Choice A is incorrect because dry heat is less likely to cause burns than moist heat. Choice B is incorrect as dry heat may not penetrate deeply into tissues. Choice D is incorrect as dry heat is less likely to cause skin breakdown compared to moist heat.
5. While caring for Mrs. Thomas, you see a notation on the nursing care plan that states 'ambulate at least 10 yards qid'. This patient will be assisted with ambulation at which of the following times?
- A. 10:00 AM
- B. 10 am and 2 pm
- C. 10 am and 2 pm
- D. 10 am, 2 pm, 6 pm, and 10 pm
Correct answer: D
Rationale: The correct answer is to assist the patient with ambulation at 10 am, 2 pm, 6 pm, and 10 pm as qid stands for four times per day. This schedule is commonly followed in healthcare facilities to ensure regular ambulation and exercise for the patient. Choices A, B, and C do not cover all the specified times for ambulation as indicated by the qid notation on the care plan.
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