Published - Thu, 23 Feb 2023

NCLEX-PN Exam Questions - Part 120

1. The nurse should perform which intervention when a client is restrained?

A) Remove the restraints and provide skin care hourly.
B) Document the condition of the client - s skin every 3 hours.
C) Assess the restraint every 30 minutes.
D) Tie the restraint to the side rails.

2. A client receives a cervical intracavity radium implant as part of her therapy. A common side effect of a cervical implant is:

A) creamy, pink-tinged vaginal drainage.
B) stomatitis.
C) constipation.
D) xerostomia.

3. An appropriate question when assessing a client - s self-expectations about weight loss is:

A) 'What makes you think you can change your eating habits?'
B) 'How do you feel about losing weight?'
C) 'How important is it that you lose weight?'
D) 'What do you think is a realistic weekly weight loss for you?'

4. Which of the following statements should the nurse use to best describe a very low-calorie diet (VLCD) to a client?

A) 'This diet can be used when there is close medical supervision.'
B) 'This is a long-term treatment measure that assists obese people who can - t lose weight.'
C) 'The VLCD consists of solid food items that are pureed to facilitate digestion and absorption.'
D) 'A VLCD contains very little protein.'

5. A client has been placed in isolation because he is diagnosed with a contagious illness. The nurse should be aware that:

A) Linens from the client - s bed should be double-bagged.
B) Meals should be served on washable dishes.
C) Extensive isolation rarely causes psychological problems.
D) Paper trays and plastic utensils prevent disease transmission.

1. Right Answer: C
Explanation: The minimum standard is to visually assess the restraint every 30 minutes. Documentation is typically performed per a checklist or flow sheet. The ends of the restraint are tied to a part of the bed that allows for position changes without unfastening them. Safety and Infection Control

2. Right Answer: A
Explanation: Creamy, pink-tinged vaginal drainage persists for 1 to 2 months after removal of a cervical implant. Diarrhea, not constipation, is usually a side effect of cervical implants. Stomatitis and xerostomia are local side effects of radiation to the mouth. Physiological Adaptation

3. Right Answer: D
Explanation: Nurses should assist clients to evaluate themselves and make behavior changes. Listening to clients, supporting clients strengths, assisting clients to look at themselves in totality, and encouraging clients to set attainable goals should be part of the nurse-client relationship. Psychosocial Integrity

4. Right Answer: A
Explanation: VLCDs are used in the clinical treatment of obesity under close medical supervision. The diet is low in calories, high in quality of protein, and has a minimum of carbohydrates to spare protein and prevent ketosis. Physiological Adaptation

5. Right Answer: A
Explanation: Linens should be double-bagged. Isolation refers to techniques used to prevent or to limit the spread of infection. Some form of isolation has been used for centuries, whether to protect a high-risk person from exposure to pathogens or to prevent the transmission of pathogens from an infected person to others.Special handling of articles and linen soiled by any body fluid is indicated. These articles should be placed in impervious bags before they are removed from the clients bedside. Bagging in watertight containers is indicated to prevent exposure of personnel and contamination of the environment. The outside of the bag should not be contaminated when placing articles inside it. Each hospital and community agency has procedures for labeling and decontaminating exposed articles. Items that are visibly soiled with body substances should be rinsed and placed in plastic bags or clearly marked containers, often labeled 'Contaminated.'If the outside of the bag becomes contaminated, placing that bag in another bag (double-bagging) is required. Safety and Infection Control

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