a nurse is preparing to insert an indwelling catheter in a female client which of the following positions of the client is most appropriate for this p

NCLEX-RN

Health Promotion and Maintenance NCLEX RN Questions

1. A healthcare professional is preparing to insert an indwelling catheter in a female client. Which of the following positions of the client is most appropriate for this procedure?

A. Lithotomy position
B. Prone position
C. Dorsal recumbent position
D. High Fowler's position

Correct answer: C

Rationale: When preparing to insert an indwelling catheter for a female client, the most appropriate position is the dorsal recumbent position. In this position, the client lies on their back with knees bent. This position allows for easy access to the urethral area for catheter insertion. The lithotomy position, with legs elevated and spread apart, is more invasive and typically used for gynecological exams. The prone position, lying face down, is not suitable for catheter insertion. High Fowler's position, sitting upright at a 90-degree angle, is not ideal for catheter insertion as it does not provide proper access to the perineal area.

2. An infant is brought to the clinic by his mother, who has noticed that he holds his head in an unusual position and always faces to one side. Which of the following is the most likely explanation?

A. Torticollis, with shortening of the sternocleidomastoid muscle
B. Craniosynostosis, with premature closure of the cranial sutures
C. Plagiocephaly, with flattening of one side of the head
D. Hydrocephalus, with increased head size

Correct answer: A

Rationale: The correct answer is torticollis, characterized by the shortening of the sternocleidomastoid muscle, limiting the range of motion of the neck and causing the chin to point to the opposing side. Craniosynostosis is the premature closure of cranial sutures, leading to an abnormal head shape but not necessarily affecting head position. Plagiocephaly is flattening of one side of the head due to external forces or positioning, not muscle shortening. Hydrocephalus presents with an increased head size due to the accumulation of cerebrospinal fluid, not with a fixed head position.

3. While caring for a client who has just come from surgery and is in the recovery room with an endotracheal tube in place, the nurse deflates the cuff on the tube and removes it. The client sits up in bed, grasps his throat, and begins to make wheezing sounds. Which of the following conditions is the most likely cause of this situation?

A. The client is choking on part of the tube
B. The client has anxiety
C. The client is having a laryngospasm
D. The client is having a normal response from anesthesia

Correct answer: D

Rationale: After surgery, some clients may experience a laryngospasm during emergence from anesthesia. A laryngospasm can lead to the closure of the laryngeal opening due to spasm of the vocal cords. In this scenario, the client's symptoms of wheezing and throat grasping are indicative of a laryngospasm rather than choking on the tube, anxiety, or a normal response from anesthesia. The nurse should act promptly to open the airway to aid breathing and consider administering muscle relaxants as necessary.

4. Albert is a patient in the hospital who is scheduled for surgery the following morning. After the pre-operative visit from the anesthesia staff member who has obtained surgical consent, Albert asks for an explanation of what type of surgery he is going to have. He states that he's not sure what he just signed. What is your best response?

A. Don't worry, they'll explain it in the operating room.
B. It's standard procedure to get the consent; you don't need to worry.
C. Let me ask the nurse anesthetist to come back and explain it further.
D. Someone will review it with you prior to surgery.

Correct answer: C

Rationale: The correct response is to ensure that the patient fully understands the nature of the surgery they are about to undergo. If the patient expresses uncertainty about the procedure they signed consent for, it indicates a lack of informed consent, which is essential before any surgery. By requesting the nurse anesthetist to return and provide a more detailed explanation, the patient can make an informed decision. Choices A, B, and D do not address the issue of the patient's lack of understanding and the need for informed consent, making them incorrect. Option C is the best course of action to rectify the situation and ensure the patient's understanding and consent are properly obtained.

5. What preparation is necessary for a colposcopy procedure?

A. NPO for 8-12 hours before the procedure.
B. D/C all hypertension medications for two days prior to the procedure.
C. Take three Dulcolax tablets and two containers of Miralax the day before to clear out the lower GI system.
D. None of the above prep is necessary for this type of procedure.

Correct answer: D

Rationale: A colposcopy procedure is performed to examine the vagina and cervix. The only preparation required is washing the external genitals with soap and water on the morning of the procedure. Choices A, B, and C suggest unnecessary preparations that are not relevant to a colposcopy. NPO for 8-12 hours, discontinuing hypertension medications, and using laxatives are not part of the standard preparation for a colposcopy.