NCLEX-RN
NCLEX RN Exam Prep
1. A nurse is preparing to irrigate a client's indwelling catheter through a closed, intermittent system. Which of the following steps must the nurse take as part of this process?
- A. Use sterile solution at room temperature
- B. Position the client in a comfortable position
- C. Clamp the catheter at the level above the injection port
- D. Inject sterile solution through the injection port into the catheter
Correct answer: D
Rationale: When performing closed intermittent system catheter irrigation, the nurse should use sterile solution at room temperature with sterile technique. It is important to position the client comfortably for easy access to the catheter site and to assess the abdomen during the procedure. Clamping the catheter should be done below the level of the injection port, not above. The correct step is to inject sterile solution through the injection port into the catheter, allowing the fluid to travel up the catheter to irrigate the tubing and the bladder.
2. Which of the following questions is considered open-ended?
- A. What time did you last take your medications?
- B. Are you feeling okay right now?
- C. Please describe your symptoms.
- D. What day are you available for a follow-up appointment?
Correct answer: C
Rationale: The correct answer is 'Please describe your symptoms.' This question is considered open-ended because it encourages the respondent to provide a detailed and descriptive answer, fostering a more elaborate response. Open-ended questions are designed to prompt thoughtful and detailed responses. Choice A is a closed-ended question since it seeks a specific time for the medication intake. Choice B is also closed-ended as it can be answered with a simple 'yes' or 'no,' limiting the response. Choice D is closed-ended as it requests a specific day for the follow-up appointment, restricting the range of possible responses.
3. In which situation would the nurse use bimanual palpation technique?
- A. Palpating the thorax of an infant
- B. Palpating the kidneys and uterus
- C. Assessing pulsations and vibrations
- D. Assessing the presence of tenderness and pain
Correct answer: B
Rationale: Bimanual palpation involves using both hands to envelop or capture specific body parts or organs like the kidneys, uterus, or adnexa. This technique is particularly useful for assessing the size, shape, consistency, and mobility of deep organs like the kidneys and uterus. Palpating the thorax of an infant (Choice A) is usually done with a different technique like gentle, single-handed palpation. Assessing pulsations and vibrations (Choice C) and assessing tenderness and pain (Choice D) typically do not require the use of bimanual palpation, making Choices A, C, and D incorrect.
4. What does the medical term 'basophilia' refer to?
- A. An attachment of the epithelial cells of the skin to a basement membrane
- B. An overabundance of a particular white blood cell in the peripheral blood
- C. An underrepresentation of basophils on a blood smear
- D. None of the above
Correct answer: B
Rationale: The correct answer is 'An overabundance of a particular white blood cell in the peripheral blood.' Basophilia specifically indicates an increased number of basophils in the peripheral blood. It can be observed in conditions like leukemia and certain allergic reactions. Choice A is incorrect as it describes something unrelated to basophilia. Choice C is incorrect as it suggests a decrease in basophils, which is opposite to the actual meaning of basophilia. Choice D is also incorrect as basophilia does have a defined medical significance.
5. In which of the following ways can a healthcare provider promote the sense of taste for an older adult?
- A. Mixing foods together on the dinner tray
- B. Avoiding cologne, air fresheners, or room deodorizers
- C. Encouraging the client to chew food thoroughly
- D. Discouraging the use of salt or seasonings with prepared food
Correct answer: C
Rationale: As individuals age, their sense of taste may diminish, impacting the enjoyment of eating. One effective way for a healthcare provider to promote the sense of taste for an older adult is by encouraging them to chew food thoroughly. Thorough chewing increases the contact of food with the taste buds, enhancing the chances of experiencing the flavors. Mixing foods together on the dinner tray may not necessarily enhance taste perception. Avoiding strong scents like cologne, air fresheners, or room deodorizers is more related to olfactory senses rather than taste. Discouraging the use of salt or seasonings can further diminish the taste experience for older adults who may already have reduced taste sensitivity.
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