NCLEX-RN ACTUAL EXAM TEST QUESTIONS & ANSWERS

NCLEX-RN ACTUAL
EXAM TEST QUESTIONS
& ANSWERS



The nurse is instructing a client who has had an ileostomy about
the diet following surgery. The nurse should tell the client:
"Limit your fluids to 1,000 mL/day."
"Chew your food thoroughly."
"There is no need to monitor your diet."
"Six small meals a day will prevent abdominal distention." -
ANSWER-The client is instructed to chew food well to aid
digestion and prevent obstruction.The client should maintain an
adequate fluid intake.The client is usually placed on a regular
diet but is encouraged to eat high-fiber, high-cellulose foods
(e.g., nuts, popcorn, corn, peas, tomatoes) with caution; these
foods may swell in the intestine and cause an obstruction.Eating
six small meals a day is not necessary.
A client in the second stage of labor who planned an
unmedicated birth is in severe pain because the fetus is in the
ROP position. The nurse should place the client in which
position for pain relief?
lithotomy
right lateral
hands and knees
tailor sitting - ANSWER-Placing the client in the hands and
knees position pulls the fetal head away from the sacral
promontory (relieving pain) and facilitates rotation of the fetus to
the anterior position. Lithotomy is the position preferred by some
health care providers (HCP) for delivery but does not facilitate
rotation. The right lateral position will perpetuate the ROP(right
occiput posterior: sunny side-up) position. Tailor sitting
facilitates descent in OA positions.
A client in a hospice program has increasing pain, and the nurse
is collaborating with the client to make a pain management plan.
Which plan will be most effective for the client?
administering doses of analgesic when pain is a "5" on a scale
of 1 to 10.
providing enough analgesia to keep the client semi-somnolent
allowing an analgesia-free period so that the client can carry out
daily hygienic activities.
administering pain medications over a 24-hour period -
ANSWER-The desired outcome for management of pain is that
the client's or family's subjective report of pain is acceptable and
documented using a pain scale; the goal is that behavioral and
physiologic indicators of pain are absent around the clock. The
nurse and client/family should develop a systematic approach to
pain management using information gathered from history and a
hierarchy of pain measurement. Pain should be assessed at
frequent intervals. The client should not wait to receive
medication until the pain is midpoint on the pain scale, nor
should the client receive so much pain medication that he or she
is not alert. Continuous pain relief is the goal, not just during
particular periods during the day.