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NCLEX-PN Exam Questions - Part 89
1. 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.
2. 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.
3. 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
4. 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.
5. 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.
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.
2. 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.
3. 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
4. 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.
5. 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.
1. Right Answer: B
Explanation: 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. Basic Care and Comfort
2. Right Answer: B
Explanation: 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. Basic Care and Comfort
3. Right Answer: B
Explanation: The client cannot speak to alert the nurse to his pain state. The nurse needs to provide alternate methods of communication with the client. Basic Care andComfort
4. Right Answer: A
Explanation: 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. Basic Care and Comfort
5. Right Answer: C
Explanation: 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. Basic Care and Comfort
Explanation: 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. Basic Care and Comfort
2. Right Answer: B
Explanation: 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. Basic Care and Comfort
3. Right Answer: B
Explanation: The client cannot speak to alert the nurse to his pain state. The nurse needs to provide alternate methods of communication with the client. Basic Care andComfort
4. Right Answer: A
Explanation: 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. Basic Care and Comfort
5. Right Answer: C
Explanation: 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. Basic Care and Comfort
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