NCLEX-RN
NCLEX RN Exam Prep
1. 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.
2. 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.
3. When cleansing the genital area during perineal care, the nurse should _____________.
- A. cleanse the penis with a circular motion starting from the base and moving toward the tip.
- B. replace the foreskin after it has been pushed back to cleanse an uncircumcised penis.
- C. cleanse the rectal area first and then clean the patient's genital area.
- D. use the same area on the washcloth for each washing and rinsing stroke for a female resident.
Correct answer: B
Rationale: During perineal care, when cleansing the genital area of an uncircumcised male patient, it is crucial to retract the foreskin to clean the area underneath. This helps in the removal of smegma, a substance that can accumulate and lead to bacterial growth and infection if not cleaned properly. The foreskin should then be replaced back to its original position after cleaning to ensure proper hygiene and prevent any potential complications. Choices A, C, and D are incorrect because they do not address the specific care required for an uncircumcised penis, which involves retracting and replacing the foreskin.
4. The rehabilitation nurse wishes to make the following entry into a client's plan of care: 'Client will reestablish a pattern of daily bowel movements without straining within two months.' The nurse would write this statement under which section of the plan of care?
- A. Nursing diagnosis/problem list
- B. Nursing orders
- C. Short-term goals
- D. Long-term goals
Correct answer: D
Rationale: The correct answer is 'Long-term goals.' Long-term goals are designed to describe changes in client behavior expected over a time frame greater than one week. In this case, the goal of reestablishing a pattern of daily bowel movements without straining within two months falls under a long-term goal. Long-term goals are aimed at restoring normal functioning in a problem area and are beneficial for healthcare workers caring for the client across different settings. Choices A, B, and C are incorrect because nursing diagnosis/problem list, nursing orders, and short-term goals do not encompass the desired timeframe or level of expected change in this scenario.
5. A client who complains of nausea and seems anxious is admitted to the nursing unit. The nurse should take which of the following actions regarding completion of the admission interview?
- A. Help the client to get settled and conduct the interview the next morning when the client is rested
- B. Conduct the interview immediately, directing the majority of the questions to the client
- C. Conduct the interview as soon as uninterrupted time is available to address the client's concerns
- D. Ask the charge nurse to interview the client while the admitting nurse calls the doctor for anti-nausea and anti-anxiety medication
Correct answer: C
Rationale: When dealing with a client who is experiencing nausea and anxiety, it is important to promptly conduct the admission interview to address their concerns. This allows for the collection of accurate data while attending to the client's immediate needs. Delaying the interview until the next morning (Choice A) may not be in the best interest of the client as timely assessment and intervention are essential. Directing questions to the client's spouse (Choice B) may not provide accurate information from the client themselves. Asking another nurse to conduct the interview while administering medications (Choice D) does not prioritize building a therapeutic relationship with the client, which is crucial in addressing their concerns and providing holistic care.
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