NCLEX NCLEX Certifications NCLEX-PN Questions & Answers

• Question 421:

  The nurse is turning a client who has a new prosthetic hip.

  Which position should be avoided to prevent injury to the new prosthetic hip?

  A. abduction of the hip

  B. adduction of the hip

  C. flexing the hip at 80?flexion

  D. flexing the hip at 90?

  Correct Answer: B

  New prosthetic hips should have an abduction pillow in place to avoid adduction.

• Question 422:

  A client with cirrhosis of the liver presents with ascites. The physician is to perform a parancentesis. For safety, the nurse should ask the client to __________.

  A. drink 1000 cc prior to the procedure to affect fluid loss

  B. eat foods low in fat

  C. empty his bladder prior to the procedure

  D. assume the prone position

  Correct Answer: C

  When performing a parancentesis, the client must be sitting up to allow the fluid to settle to the lower

  abdomen.

  To prevent trauma to the bladder while inserting a needle to aspirate the fluid, the bladder must be empty.

• Question 423:

  A spinal change occurring with pregnancy that alters mobility is __________.

  A. scoliosis

  B. kyphosis

  C. lordosis

  D. ankylosing spondylitis

  Correct Answer: C

  The spinal change occurring with pregnancy is lordosis.

  This occurs due to the weight of the enlarging uterus and the effect of gravity.

• Question 424:

  A client is to have an enema to reduce flatus. The enema tube should be inserted __________.

  A. 4 inches

  B. 6 inches

  C. 2 inches

  D. 8 inches

  Correct Answer: A

  Enema tubing must be passed beyond the internal sphincter.

  Two inches is not far enough to pass the internal sphincter.

  Both 6 and 8 inches are too far and might cause trauma to the bowel.

• Question 425:

  An 80-year-old aphasic CVA client had abdominal surgery 2 days ago.

  Which of the following puts this client at the highest risk for inadequate pain management?

  A. inability to turn, cough, and breathe deeply

  B. inability to communicate pain

  C. inability to ambulate freely

  D. inability to use a bedside commode

  Correct Answer: B

  The client cannot speak to alert the nurse to his pain state.

  The nurse needs to provide alternate methods of communication with the client.

• Question 426:

  The hydraulic lift (Hoyer lift) is __________.

  A. used for all clients who've had orthopedic surgery

  B. used for all clients who are not able to stand and for extremity obese clients

  C. used for all clients, both old and young, in a hospital setting

  D. not an assistive device for special needs

  Correct Answer: B

  The hydraulic lift is used for safe transfer when a client is not able to stand or is too heavy for the health care workers to lift safely.

• Question 427:

  Safety measures for using crutches must be taught to clients.

  Safety measures for the use of crutches include __________.

  A. properly fitting crutches with rubber tips at the end that provide a four-point gait

  B. properly fitting crutches, education in the appropriate gait, and strength in the arms

  C. crutches that fit the way the client chooses and a gait chosen by client

  D. both legs touching the floor for all gaits

  Correct Answer: B

  In addition to the rubber tips on the ends of the crutches, the client needs to know the appropriate gait. Arm strength exercises are important, and it is critical that the client be fitted properly for the crutches.

• Question 428:

  A standard walker is used when clients __________.

  A. have poor balance, cannot stand up, have weak arms, and have good hand strength.

  B. have poor balance, have a broken leg, or have experienced amputation.

  C. have poor balance, have cardiac problems, or cannot use crutches or a cane.

  D. have poor balance, have an autoimmune disease, or have weak arms.

  Correct Answer: C

  A walker is used for clients who have balance problems, cardiac problems, or cannot use crutches or a

  cane.

  The client needs to bear partial weight and have strength in her wrists and arms.

  The client uses her upper body to propel the walker forward.

• Question 429:

  Mrs. Peterson complains of difficulty falling asleep, awakening earlier than desired, and not feeling rested. She attributes these problems to leg pain that is secondary to her arthritis.

  What is the most appropriate nursing diagnosis for her?

  A. Sleep Pattern Disturbances (related to arthritis)

  B. Fatigue (related to leg pain)

  C. Knowledge Deficit (regarding sleep hygiene measures)

  D. Sleep Pattern Disturbances (related to chronic leg pain)

  Correct Answer: D

  The client's sleep pattern is directly disturbed by the chronic leg pain, which is secondary to the arthritis. This nursing diagnosis is the appropriate one to directly deal with comfort measures and the like.

• Question 430:

  A hospitalized adult client who routinely works from midnight until 8 a.m. has a temperature of 99.1?F at 4

  a.m.

  The nurse determines that this is most likely due to __________.

  A. delta sleep

  B. slow brain waves

  C. pneumonia

  D. circadian rhythm

  Correct Answer: D

  Biological rhythms that follow a cycle lasting about 24 hours are termed circadian rhythm.

  The sleep-wake cycle is closely linked with cardiac rhythms, such as body temperature.

  While a person sleeps, core body temperature drops, often reaching the 24-hour low at 4 a.m. When the

  sleep period shifts, temperature fluctuations also shift to match the new sleep patterns.