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NCLEX-PN Exam Questions - Part 52
1. Perineal care to a female client by the nurse can be performed:
A) without gloves, pouring water from a sterile bottle.
B) without gloves, having the client perform all care.
C) with gloves, washing the perineal area from front to back.
D) with gloves, washing the perineal area from back to front.
2. When a client who is having trouble conceiving says to the nurse, 'I have started taking ginseng,' the best response by the nurse is:
A) 'No studies show that ginseng is effective for infertility.'
B) 'Some studies show that ginseng enhances in vitro sperm motility.'
C) 'Why don - t you try acupuncture instead. Many studies have shown it to be effective for infertility.'
D) 'It - s probably not going to hurt you, but it - s also probably not going to help. Let - s look at some other alternatives.'
3. A client describes her cervical mucus as clear, thin, and elastic. Upon examination, the nurse demonstrates that the cervical mucus can be stretched 810 cm.The nurse correctly documents the finding as:
A) ferning capacity.
B) lack of ferning.
C) spinnbarkheit.
D) inhospitable.
4. A client with a nasogastric (NG) tube begins vomiting. What action should the nurse take?
A) Retape the NG tube.
B) Clamp the NG tube.
C) Remove the NG tube.
D) Check the NG tube placement.
5. Which of the following is the most appropriate diet for a client who is unable to swallow?
A) nothing by mouth
B) nasogastric feedings
C) clear liquids
D) total parenteral nutrition
A) without gloves, pouring water from a sterile bottle.
B) without gloves, having the client perform all care.
C) with gloves, washing the perineal area from front to back.
D) with gloves, washing the perineal area from back to front.
2. When a client who is having trouble conceiving says to the nurse, 'I have started taking ginseng,' the best response by the nurse is:
A) 'No studies show that ginseng is effective for infertility.'
B) 'Some studies show that ginseng enhances in vitro sperm motility.'
C) 'Why don - t you try acupuncture instead. Many studies have shown it to be effective for infertility.'
D) 'It - s probably not going to hurt you, but it - s also probably not going to help. Let - s look at some other alternatives.'
3. A client describes her cervical mucus as clear, thin, and elastic. Upon examination, the nurse demonstrates that the cervical mucus can be stretched 810 cm.The nurse correctly documents the finding as:
A) ferning capacity.
B) lack of ferning.
C) spinnbarkheit.
D) inhospitable.
4. A client with a nasogastric (NG) tube begins vomiting. What action should the nurse take?
A) Retape the NG tube.
B) Clamp the NG tube.
C) Remove the NG tube.
D) Check the NG tube placement.
5. Which of the following is the most appropriate diet for a client who is unable to swallow?
A) nothing by mouth
B) nasogastric feedings
C) clear liquids
D) total parenteral nutrition
1. Right Answer: C
Explanation: Gloves should always be worn, and the perineal area should be washed with a washcloth from front to back. This method prevents E. coli and other bacteria from being swept into the urethra. The procedure should be performed and explained in a private area with all equipment gathered first. Basic Care and Comfort
2. Right Answer: B
Explanation: Some studies have shown that ginseng and astragalus have enhanced in vitro sperm motility. Ginseng has long been used in traditional Chinese medicine to enhance male fertility. So, Choice 2 is correct and directly addresses the clients comments. Many times couples struggling with infertility turn to alternative therapies in desperation. They can be very expensive, and some are harmful. Ginseng should not interfere with any of the traditional fertility treatments and might help the couple feel empowered that they are also doing something on their own. Choice 1 is not true. Choice 3 introduces another alternative therapy. It is true that acupuncture is a traditional Chinese medical therapy and has been shown in several clinical studies to be effective in treating infertility in both women and men. The best response by the nurse should address the therapy the client states she is using. Choice 4 dismisses the clients attempts to work through her issues and contribute to the solution. One concern is always that more traditional therapies might be ignored, and time might be lost to alternative therapies. But this response causes the client to perceive the nurse as unsupportive and inhibits further discussion and disclosure. Health Promotion and Maintenance
3. Right Answer: C
Explanation: Spinnbarkheit is the correct terminology to identify the cervical mucus described. This type of mucus occurs at ovulation and its assessment is used to help couples determine the time they are most likely to conceive. Ferning capacity or crystallization also increases as ovulation approaches. The only way that ferning can be identified is to place the cervical mucus on a microscope slide, let it air dry, and then examine it for a fern-type appearance. Lack of ferning cannot be determined without microscopic examination. Inhospitable cervical mucus refers to mazelike patterns of mucoid strands in cervical mucus that prohibit sperm motility. Other characteristics that make the mucus inhospitable relate to hormone levels, infection, and so on. These conditions cannot be determined by the description supplied in the question. Health Promotion and Maintenance
4. Right Answer: D
Explanation: For the client with an NG tube who begins vomiting, the nurse should check the tube placement because it might be displaced, thereby leading to vomiting. The other responses are not appropriate. Reduction of Risk Potential
5. Right Answer: B
Explanation: Nasogastric feedings are most appropriate for a client who is unable to swallow. Nothing by mouth leads to nutritional deficiencies. The client might aspirate a clear liquid diet. TPN is not necessary as long as the gut is still functioning. Reduction of Risk Potential
Explanation: Gloves should always be worn, and the perineal area should be washed with a washcloth from front to back. This method prevents E. coli and other bacteria from being swept into the urethra. The procedure should be performed and explained in a private area with all equipment gathered first. Basic Care and Comfort
2. Right Answer: B
Explanation: Some studies have shown that ginseng and astragalus have enhanced in vitro sperm motility. Ginseng has long been used in traditional Chinese medicine to enhance male fertility. So, Choice 2 is correct and directly addresses the clients comments. Many times couples struggling with infertility turn to alternative therapies in desperation. They can be very expensive, and some are harmful. Ginseng should not interfere with any of the traditional fertility treatments and might help the couple feel empowered that they are also doing something on their own. Choice 1 is not true. Choice 3 introduces another alternative therapy. It is true that acupuncture is a traditional Chinese medical therapy and has been shown in several clinical studies to be effective in treating infertility in both women and men. The best response by the nurse should address the therapy the client states she is using. Choice 4 dismisses the clients attempts to work through her issues and contribute to the solution. One concern is always that more traditional therapies might be ignored, and time might be lost to alternative therapies. But this response causes the client to perceive the nurse as unsupportive and inhibits further discussion and disclosure. Health Promotion and Maintenance
3. Right Answer: C
Explanation: Spinnbarkheit is the correct terminology to identify the cervical mucus described. This type of mucus occurs at ovulation and its assessment is used to help couples determine the time they are most likely to conceive. Ferning capacity or crystallization also increases as ovulation approaches. The only way that ferning can be identified is to place the cervical mucus on a microscope slide, let it air dry, and then examine it for a fern-type appearance. Lack of ferning cannot be determined without microscopic examination. Inhospitable cervical mucus refers to mazelike patterns of mucoid strands in cervical mucus that prohibit sperm motility. Other characteristics that make the mucus inhospitable relate to hormone levels, infection, and so on. These conditions cannot be determined by the description supplied in the question. Health Promotion and Maintenance
4. Right Answer: D
Explanation: For the client with an NG tube who begins vomiting, the nurse should check the tube placement because it might be displaced, thereby leading to vomiting. The other responses are not appropriate. Reduction of Risk Potential
5. Right Answer: B
Explanation: Nasogastric feedings are most appropriate for a client who is unable to swallow. Nothing by mouth leads to nutritional deficiencies. The client might aspirate a clear liquid diet. TPN is not necessary as long as the gut is still functioning. Reduction of Risk Potential
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