Saunders NCLEX Questions Week 3

The nurse has reviewed with the preoperative client the procedure for the administration of an enema. Which statement by the client would indicate the need for further instruction? The enema will be given while I am sitting on the toilet." "I would try and hold the fluid as long as possible after it is run in." "I know that there will be some cramping after the enema solution is run in." "I would tell the nurse if cramping occurs when the fluid is running in."

"The enema will be given while i am sitting on the toilet."

The nurse is teaching a client with a urinary stoma about how to change the collection bag and appliance at home. Which of the following client statements indicates an understanding of the procedure? "The stoma needs to be cleaned with only water." "The best time to change the appliance is at night." "The pouch needs to be changed every 5 to 7 days." "I'll cut the skin barrier 10 millimeters larger than the stoma."

"The pouch needs to be changed every 5 to 7 days."

A client states to the home health nurse that they have not had a bowel movement since coming home from the hospital after surgery 4 days ago. The nurse instructs the client to follow which diet at this time? High-fiber diet Full liquid diet Low-fiber diet Low-sodium diet

High-fiber diet

The nurse is inserting an indwelling urinary catheter. As the catheter is inserted into the urethra, urine begins to flow into the tubing. What would the nurse do next? Immediately twist the catheter, and then slowly inflate the balloon. Insert the catheter 2.5 to 5 cm farther, and then inflate the balloon. Insert the catheter until resistance is met, and then inflate the balloon. Withdraw the catheter approximately 1 in (2.5 cm), and then inflate the balloon.

Insert the catheter 2.5 to 5 cm farther, and then inflate the balloon.

The nurse is preparing to irrigate a client's sigmoid colostomy. The nurse would plan for which intervention to perform this procedure? Instilling 500 to 1000 mL of lukewarm tap water through the stoma Advising the client to hold the breath if cramping occurs during instillation of the solution Hanging the irrigation solution so that the bottom of the bag is 18 inches above the client's torso Inserting the irrigation tube with a small amount of force and a twisting motion into the stoma and unclamping the tubing to allow the solution to flow into the stoma

Instilling 500 to 1000 mL of lukewarm tap water through the stoma

Before enema administration, the nurse positions the client in a left lateral position. What is the rationale for using this position

It facilitates instillation of the enema solution into the colon.

A primary health care provider has ordered digital removal of stool for a constipated client. How would the nurse position the client for this procedure? Prone position Lithotomy position Left lateral side-lying position Right lateral side-lying position

Left lateral side-lying position

The nurse is preparing to administer a soapsuds enema to a preoperative client. In which position would the nurse place the client to administer the enema? Click on the image to indicate your answer.

Left-side lateral sims position

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse would place the client in which position? Modified left lateral position Modified right lateral position On the left side of the body, with the head of the bed elevated 45 degrees On the right side of the body, with the head of the bed elevated 45 degrees

Modified left lateral position

The client has a prescription for the administration of an enema. After preparing the equipment and solution, the nurse would assist the client into which position? Right-sided lateral position Modified left lateral position Left side, with the head of the bed elevated 45 degrees Right side, with the head of the bed elevated 45 degrees

Modified left lateral positionin

The nurse is examining a dark-skinned client for the presence of petechiae. The nurse will best observe these lesions in which body area? Sclerae Oral mucosa Sole of the foot Palm of the hand

Oral mucosa

The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How would the nurse best determine the presence of erythema? Assess for drainage from the wound. Assess for redness around the wound edges. Palpate for swelling around the wound edges. Palpate for increased skin temperature around the wound edges.

Palpate for increased skin temperature around the wound edges.

The nurse is caring for a 1-day postoperative client who is complaining of urinary retention. What are the initial assessment techniques or interventions the nurse would employ? Select all that apply. Palpation Inspection Percussion Auscultation Bladder scanner Insertion of Foley catheter

Palpation, Inspection, Percussion, Bladder scanner

The staff nurse is observing a new graduate nurse provide indwelling urinary catheter care to an uncircumcised client. Which action by the new graduate nurse would indicate a need for further teaching? Cleans the catheter proximally to distally with soap and water 2 Maintains the urinary collection bag below the level of the bladder 3 Removes a loose catheter anchor and places a new anchor on the lower leg 4 Uses the nondominant hand to pull back the foreskin to cleanse the urethral meatus with soap and water and returns the foreskin to its normal position

Removes a loose catheter anchor and places a new anchor on the lower leg

The nurse is inserting an indwelling urinary catheter in a client. As the nurse begins to inflate the balloon, the client starts to complain of pain. Which action would the nurse take? Continue to inflate the balloon. Deflate the balloon, slightly withdraw the catheter, and attempt to reinflate the balloon. 3 Deflate the balloon, completely withdraw the catheter, and end the procedure to notify the primary health care provider. 4 Stop inflating the balloon, allow the saline solution to drain into the syringe, and advance the catheter farther before reinflating the balloon.

Stop inflating the balloon, allow the saline solution to drain into the syringe, and advance the catheter farther before reinflating the balloon.

The nurse is performing colostomy irrigation on a client. During the irrigation, the client begins to complain of abdominal cramps. What is the appropriate nursing action? Stop the irrigation temporarily. Increase the height of the irrigation. Notify the primary health care provider. Medicate for pain and resume the irrigation

Stop the irrigation temporarily

A client with a colostomy has a prescription for irrigation of the colostomy. Which solution would the nurse use for the irrigation? Tap water Sterile water Sterile distilled water Sterile lactated Ringer's

Tap water

The nurse is preparing a list of client care activities to be done during the shift. For which clients would the nurse instruct the assistive personnel (AP) to use an electric razor for shaving? Select all that apply A client with leukocytosis A client with thrombocytosis A client with thrombocytopenia A client receiving an antiplatelet medication A client receiving acetaminophen as needed for mild pain

A client with thrombocytopenia A client receiving an antiplatelet medication

The nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which areas helpful in assessing for pallor or cyanosis? Select all that apply

tongue, nail beds, mucous membranes

The nurse is preparing to give a full bed bath to a client. Which question is most important for the nurse to ask the client before beginning the bed bath? "Do you have any allergies?" "Will you be able to wash your own hair?" "Are there any areas you want us to spend more time bathing?" "Do you have any preferences regarding how we help you bathe?"

"Do you have any allergies?"

The nurse is reviewing dental care with a client who is edentulous and wears dentures. Which client statement indicates an understanding of proper dental care? "Since I have no teeth, I do not need to brush my mouth." "I need to use hot water when cleaning my dentures to kill bacteria." "I will remove my dentures before bed and keep them in my labeled denture cup covered with water." "When I am not wearing my dentures during the day, I can keep them in the denture cup with no water, as they should only be in water at night."

"I will remove my dentures before bed and keep them in my labeled denture cup covered with water."

The surgeon asks the nurse to obtain a urinary catheter that will be used for continuous bladder irrigation. Which urinary catheter would the nurse obtain? A straight catheter A Coudé tip catheter A triple-lumen catheter A double-lumen.catheter

A triple-lumen catheter

The client complains of pain as the nurse is inflating the balloon during insertion of a Foley catheter. The nurse would take which immediate action?

Aspirate the fluid, advance the catheter farther, and reinflate the balloon

The nurse is making initial rounds on the nursing unit to check the condition of assigned clients. One client complains of discomfort at the intravenous (IV) site, and the nurse notes that the site is cool, pale, and swollen and that the solution is infusing slowly. What action would the nurse take first? Stop the IV infusion. Apply ice to the catheter site. Readjust the rate of IV administration. Contact the primary health care provider.

Stop the IV infusion

The nurse in a long-term care facility is observing a nursing student provide foot care to a client with diabetes mellitus. Which action by the nursing student would indicate a need for further teaching?

The nursing student applies lotion to the dorsal and plantar surfaces of the feet and in between the toes