NCLEX RN Practice Test

Opioid medications commonly cause constipation due to their effect on decreasing gastrointestinal motility. Encouraging fiber intake and increasing fluids can help alleviate mild constipation, but administering a laxative (preferably one recommended by the healthcare provider, such as a stool softener like docusate sodium) is essential for addressing constipation caused by opioids. Physical activity can also promote bowel motility but may not always be sufficient in cases of medication-induced constipation. Enemas are reserved for more severe constipation that does not respond to other interventions.

The correct action is to establish and maintain a safe environment by positioning oneself at a safe distance while using therapeutic communication techniques. Recognizing signs of escalating anger, such as pacing, clenched fists, or raised voice, allows the nurse to intervene appropriately. Maintaining a calm tone and ensuring the client's personal space can de-escalate the situation effectively and minimize the risk of harm. Other actions, such as directly instructing the client to calm down, may come across as confrontational and escalate the tension. Physical contact, such as touching the client, might increase agitation and breach their personal space. Ignoring the client entirely or failing to engage disregards the immediate risk and presents a missed opportunity to address the escalation.

The correct answer is to confirm that the healthcare provider has certified the client’s death. This step is essential to ensure that post-mortem care can proceed within the legal and institutional framework. Failing to have the death certified before proceeding with other actions, such as removing tubes or notifying the family, can lead to legal and procedural complications. The incorrect options focus on important but subsequent steps, such as notifying the family, positioning the client, or removing medical devices, which should follow the documentation of death by the healthcare provider.

The correct answer is to prioritize patient safety by implementing the RACE protocol: Rescue, Activate the alarm, Confine the fire, and Extinguish/Evacuate. The first action is to rescue the patient in immediate danger and bring them to a safe location. Following this, activating the fire alarm ensures that additional help is summoned. Although extinguishing the fire and notifying other staff are important, they come only after the patient is secured and the alarm is raised. Closing the doors is also critical but must be done after removing the patient to avoid putting them in further danger.

Using a professional interpreter ensures accurate communication between the nurse and the client, reducing the risk of misunderstandings during health education. Family members may unintentionally misinterpret medical terms or provide subjective summaries, which could compromise the client's understanding. Pointing to images or using diagrams might help but cannot guarantee comprehension of critical postoperative instructions. Avoiding medical terminology entirely does not address the client’s language barrier effectively.

Folic acid is essential for preventing neural tube defects (NTDs), such as spina bifida and anencephaly, in the developing fetus. Neural tube formation occurs within the first few weeks of pregnancy, often before a woman knows she is pregnant, which is why adequate folic acid intake during early pregnancy is critical. The incorrect options represent potential benefits of other nutrients or general pregnancy care but are not the primary role of folic acid.

Identifying individuals within the client's social network (e.g., family or friends) who actively participate in their care helps provide a clearer picture of the support system's strength. This information is crucial for developing a comprehensive care plan that includes practical and emotional assistance. Referring to community resources, while valuable, should be considered after understanding the existing support network. Simply asking how the client feels does not provide sufficient detail about their actual support system. Observing family dynamics is important but does not directly assess which individuals are actively capable of providing support.

The correct answer emphasizes taking the medication consistently at the prescribed time and following the healthcare provider's specific instructions. This ensures therapeutic efficacy and minimizes risks of improper administration. The incorrect answers suggest actions that are unsafe or non-evidence-based. For instance, doubling doses after missing one increases the risk of toxicity, storing medications in a bathroom is discouraged due to moisture and heat that can degrade the drug, and taking medications with grapefruit juice can interfere with drug metabolism, potentially leading to harmful side effects or altered effectiveness.

The correct answer is to ask open-ended questions about who the client feels they can rely on for emotional and physical support. Open-ended questioning fosters a deeper exploration of the client’s social connections and helps identify potential individuals or resources that may provide support. Other choices, such as directly contacting family members or making immediate referrals, are premature until the client’s preferences and existing relationships are fully understood. Providing informational brochures is valuable but does not assess the current support system, which is the primary goal in this scenario.

Urine output consistently below 30 mL/hour in an adult is often a sign of diminished kidney function, dehydration, or compromised fluid balance, all of which require prompt evaluation and targeted interventions. Notifying the healthcare provider is the safest and most appropriate step because it allows for further diagnostic evaluation and treatment adjustments, such as modifying fluid administration or addressing potential renal impairment. Increasing the fluid administration rate without an order can lead to complications such as fluid overload. Waiting to monitor further can delay treatment and exacerbate the issue. Administering a diuretic without understanding the underlying cause could harm the patient, as decreased urine output might indicate hypovolemia rather than fluid overload.

The correct answer is repositioning the client to improve oxygenation, as this is an appropriate task within the practical nurse’s scope of practice and directly addresses the client’s immediate need for basic respiratory support. Administering oxygen therapy may also be delegated if the supervising nurse provides clear instructions, but the wording in this option could lead to confusion by implying independent decision-making, which is outside the practical nurse's role. Diagnosing a condition or deciding to call a rapid response team are clearly outside the practical nurse’s scope of practice, as those actions involve critical decision-making reserved for registered nurses or advanced providers.

Ensuring medications are stored in a locked, temperature-controlled environment prevents unauthorized access and maintains drug efficacy. Medications require protection from environmental factors like heat or light that can compromise their stability. Labeling medications clearly with expiration dates also supports safe use, but it does not encompass the security aspect of medication control.

The correct answer focuses on actively involving the community in the planning and implementation of the program, which increases the likelihood of buy-in and sustained behavior change. Community involvement fosters a sense of ownership, relevance, and applicability to their specific health needs. The other answers are less effective because they do not account for collaboration or community-specific tailoring. For example, a lecture-based approach is often passive and may not lead to long-term engagement, while distributing generic literature typically lacks personalization and does not guarantee understanding or action.

Teaching the correct use of prescribed inhalers, including their purpose and timing (such as distinguishing between a rescue and maintenance inhaler), lays the foundation for effective asthma management. While identifying and avoiding triggers like dust and pet dander is important for reducing long-term exacerbations, ensuring the correct use of inhalers is crucial for delivering medication accurately and controlling the condition. Encouraging physical activity is age-appropriate but should follow proper asthma management and symptom control. Educating about responding to acute symptoms is critical but not adequate alone for long-term management, which includes understanding both preventive and rescue medications.

Encouraging the client to consume small, frequent, nutrient-dense meals is the best intervention because it supports the client's nutritional intake while considering their reduced appetite and physical condition. Offering oral nutritional supplements is an appropriate option, but this alone may not fully address the underlying issue of decreased food intake. Consulting a dietitian is an important step, but it does not immediately address the current nutritional deficit and requires collaboration within the care team. Monitoring intake is critical but should be done alongside more proactive interventions to improve nutritional status.