NCLEX PN 2nd Edition Test Bank 250 New Generation Question & Answers

NCLEX PN 2nd Test Bank 250 New Generation Question & Answers P A R T O N E – Fundamentals of Nursing Basic physical care 1. A nurse is caring for a client who sustained a chemical burn in his right eye. She’s preparing to irrigate the eye with sterile normal saline solution. Which steps are appropriate when performing the procedure? Select all that apply. _ 1. Tilt the client’s head toward his left eye. _ 2. Place absorbent pads in the area of the client’s shoulder. _ 3. Wash hands and put on gloves. _ 4. Place the irrigation syringe directly on the cornea. _ 5. Direct the solution onto the exposed conjunctival sac from the inner to outer canthus. _ 6. Irrigate the eye for 1 minute. Answer: 2, 3, 5 Rationale: The nurse should place absorbent pads in the area of the shoulder to prevent saturating the client’s clothing and bed linens. She should also wash her hands and put on gloves to reduce the transmission of microorganisms. The solution should be directed from the inner to outer canthus of the eye to prevent contamination of the unaffected eye. The head should be tilted toward the affected (right) eye to facilitate drainage and to prevent irrigating solution from entering the left eye. The irrigation syringe should be held about 1_ (2.5 cm) above the eye to prevent injury to the cornea. In a chemical exposure, the eye should be irrigated for at least 10 minutes. Nursing process step: Implementation Client needs category: Physiological integrity Client needs subcategory: Reduction of risk potential Cognitive level: Application 2. A nurse is caring for a client who underwent cardiac catheterization. He starts bleeding from his left femoral access site. Identify the area where the nurse should apply pressure. Answer: Rationale: The femoral artery is punctured approximately 2 inches above the access site. Nursing process step: Implementation Client needs category: Physiological integrity Client needs subcategory: Reduction of risk potential Cognitive level: Application 3. A nurse is preparing to leave a contact isolation room. Place the following steps in ascending chronological order as to how protective wear should be removed. Use all the options. Answer: Rationale: Removal of gloves, then mask, gown, and eyewear, and then washing hands for a minimum of 10 seconds limits the possibility of contact with contaminants. Nursing process step: Implementation Client needs category: Safe, effective care environment Client needs subcategory: Safety and infection control Cognitive level: Comprehension B A S I C P H Y S I C A L C AR E 3 4. A client is ordered to receive a sodium phosphate enema for relief of constipation. Proper administration of the enema includes which steps? Select all that apply. _ 1. Chill the solution by placing it in the refrigerator for 10 minutes. _ 2. Assist the client into Sims’ position. _ 3. Wash hands and put on gloves. _ 4. Insert the tip of the container 1⁄2_ into the rectum. _ 5. Allow gravity to instill the solution. _ 6. Encourage the client to retain the solution for 5 to 15 minutes. Answer: 2, 3, 6 Rationale: To administer an enema, the nurse should place the client in Sims’ position or a knee-chest position. Washing hands and putting on gloves are necessary to reduce the transmission of microorganisms. To promote the effectiveness of the enema, the nurse should encourage the client to retain the solution for at least 5 minutes. The solution should be warmed rather than chilled to promote comfort. To administer the solution effectively and deliver it to the appropriate location, the nurse should insert the full length of the tip into the rectum. The nurse should compress the container to deliver the solution under positive pressure and not by gravity. Nursing process step: Implementation Client needs category: Physiological integrity Client needs subcategory: Basic care and comfort Cognitive level: Application 1. Remove eyewear. 2. Remove gloves. 4. Remove gown. 3. Remove mask. 5. Wash hands for a minimum of 10 seconds. 2. Remove gloves. 3. Remove mask. 1. Remove eyewear. 4. Remove gown. 5. Wash hands for a minimum of 10 seconds. 5. A nurse is completing the intake and output record for a client who was restarted on his regular diet after being on nothing-by-mouth status for laboratory studies. The client has had the following intake and output during the shift: Intake: 4