PNLE 1 for foundation of proffesional nursing practice
questions and answers 2023 with complete solution
When caring for a male client with a 3-cm stage I pressure ulcer on the coccyx, which of
the following actions can the nurse institute independently?
Using normal saline solution to clean the ulcer and applying a protective dressing as
necessary.
Rationale: Washing the area with normal saline solution and applying a protective
dressing are within the nurse's realm of interventions and will protect the area. Using a
povidone-iodine wash and an antibiotic cream require a physician's order. Massaging
with an astringent can further damage the skin.
In assisting a female client for immediate surgery, the nurse In-charge is aware that she
should:
Assist the client in removing dentures and nail polish.
Rationale:Dentures, hairpins, and combs must be removed. Nail polish must be
removed so that cyanosis can be easily monitored by observing the nail beds.
Which of the following vital sign assessments that may indicate cardiogenic shock after
myocardial infarction?
BP - 80/60, Pulse - 110 irregular
Rationale:The classic signs of cardiogenic shock are low blood pressure, rapid and
weak irregular pulse, cold, clammy skin, decreased urinary output, and cerebral
hypoxia.
A 45 year old client, has no family history of breast cancer or other risk factors for this
disease. Nurse John should instruct her to have mammogram how often?
Once per year
Rationale:Yearly mammograms should begin at age 40 and continue for as long as the
woman is in good health. If health risks, such as family history, genetic tendency, or
past breast cancer, exist, more frequent examinations may be necessary.
Nurse Len refers a female client with terminal cancer to a local hospice. What is the
goal of this referral?
To provide support for the client and family in coping with terminal illness.
Rationale: Hospices provide supportive care for terminally ill clients and their families.
Hospice care doesn't focus on counseling regarding health care costs. Most client
referred to hospices have been treated for their disease without success and will
receive only palliative care in the hospice.
Nurse Oliver is assessing a client's abdomen. Which finding should the nurse report as
abnormal?
Shifting dullness over the abdomen
Rationale: Shifting dullness over the abdomen indicates ascites, an abnormal finding.
The other options are normal abdominal findings.
The nurse In-charge in labor and delivery unit administered a dose of terbutaline to a
client without checking the client's pulse. The standard that would be used to determine
if the nurse was negligent is:
,terbutaline- help to delay birth, which may give time to allow women to be transferred to
tertiary care or to complete a course of antenatal
The actions of a reasonably prudent nurse with similar education and experience.
Rationale: The standard of care is determined by the average degree of skill, care, and
diligence by nurses in similar circumstances.
Nurse Reese is teaching a female client with peripheral vascular disease about foot
care; Nurse Reese should include which instruction?
Peripheral Vascular disease-is a blood circulation disorder that causes the blood
vessels outside of your heart and brain to narrow, block, or spasm. This can happen in
your arteries or veins. PVD typically causes pain and fatigue, often in your legs, and
especially during exercise.
Avoid wearing canvas shoes.
Rationale: The client should be instructed to avoid wearing canvas shoes. Canvas
shoes cause the feet to perspire, which may, in turn, cause skin irritation and
breakdown. Both cotton and cornstarch absorb perspiration. The client should be
instructed to cut toenails straight across with nail clippers.
A newly admitted female client was diagnosed with agranulocytosis. The nurse
formulates which priority nursing diagnosis?
Agranulocytosis- also known as agranulosis or granulopenia, is an acute condition
involving a severe and dangerous lowered white blood cell count (leukopenia, most
commonly of neutrophils) and thus causing a neutropenia in the circulating blood.
Risk for infection
Rationale: Agranulocytosis is characterized by a reduced number of leukocytes
(leucopenia) and neutrophils (neutropenia) in the blood. The client is at high risk for
infection because of the decreased body defenses against microorganisms. Deficient
knowledge related to the nature of the disorder may be appropriate diagnosis but is not
the priority.
Nurse Oliver is caring for a client with impaired mobility that occurred as a result of a
stroke. The client has right sided arm and leg weakness. The nurse would suggest that
the client use which of the following assistive devices that would provide the best
stability for ambulating?
Quad cane
Rationale: Crutches and a walker can be difficult to maneuver for a client with weakness
on one side. A cane is better suited for client with weakness of the arm and leg on one
side. However, the quad cane would provide the most stability because of the structure
of the cane and because a quad cane has four legs.
A male client with a right pleural effusion noted on a chest X-ray is being prepared for
thoracentesis. The client experiences severe dizziness when sitting upright. To provide
a safe environment, the nurse assists the client to which position for the procedure?
pleural effusion- sometimes referred to as "water on the lungs," is the build-up of excess
fluid between the layers of the pleura outside the lungs.
Left side-lying with the head of the bed elevated 45 degrees.
Rationale: To facilitate removal of fluid from the chest wall, the client is positioned sitting
, at the edge of the bed leaning over the bedside table with the feet supported on a stool.
If the client is unable to sit up, the client is positioned lying in bed on the unaffected side
with the head of the bed elevated 30 to 45 degrees.
Cherry notes down ideas that were derived from the description of an investigation
written by the person who conducted it. Which type of reference source refers to this?
Primary source
Rationale: This refers to a primary source which is a direct account of the investigation
done by the investigator. In contrast to this is a secondary source, which is written by
someone other than the original researcher.
A client is admitted with multiple pressure ulcers. When developing the client's diet plan,
the nurse should include:
Pressure ulcers (also known as pressure sores or bedsores) are injuries to the skin and
underlying tissue, primarily caused by prolonged pressure on the skin. They can happen
to anyone, but usually affect people confined to bed or who sit in a chair or wheelchair
for long periods of time.
Ground beef patties
Rationale: Meat is an excellent source of complete protein, which this client needs to
repair the tissue breakdown caused by pressure ulcers. Oranges and broccoli supply
vitamin C but not protein. Ice cream supplies only some incomplete protein, making it
less helpful in tissue repair.
Ensuring that there is an informed consent on the part of the patient before a surgery is
done, illustrates the bioethical principle of:
Autonomy
Rationale: Informed consent means that the patient fully understands about the surgery,
including the risks involved and the alternative solutions. In giving consent it is done
with full knowledge and is given freely. The action of allowing the patient to decide
whether a surgery is to be done or not exemplifies the bioethical principle of autonomy.
A male client is admitted and diagnosed with acute pancreatitis after a holiday
celebration of excessive food and alcohol. Which assessment finding reflects this
diagnosis?
Pancreatitis is pathologic inflammation of the pancreas. Your pancreas sits behind your
stomach, near your small intestine.
Sudden onset of continuous epigastric and back pain
Rationale: The autodigestion of tissue by the pancreatic enzymes results in pain from
inflammation, edema, and possible hemorrhage. Continuous, unrelieved epigastric or
back pain reflects the inflammatory process in the pancreas.
Nurse Myrna is providing instructions to a nursing assistant assigned to give a bed bath
to a client who is on contact precautions. Nurse Myrna instructs the nursing assistant to
use which of the following protective items when giving bed bath?
Contact Precautions refer to infection prevention and control interventions
Gown and gloves
Rationale: Contact precautions require the use of gloves and a gown if direct client
questions and answers 2023 with complete solution
When caring for a male client with a 3-cm stage I pressure ulcer on the coccyx, which of
the following actions can the nurse institute independently?
Using normal saline solution to clean the ulcer and applying a protective dressing as
necessary.
Rationale: Washing the area with normal saline solution and applying a protective
dressing are within the nurse's realm of interventions and will protect the area. Using a
povidone-iodine wash and an antibiotic cream require a physician's order. Massaging
with an astringent can further damage the skin.
In assisting a female client for immediate surgery, the nurse In-charge is aware that she
should:
Assist the client in removing dentures and nail polish.
Rationale:Dentures, hairpins, and combs must be removed. Nail polish must be
removed so that cyanosis can be easily monitored by observing the nail beds.
Which of the following vital sign assessments that may indicate cardiogenic shock after
myocardial infarction?
BP - 80/60, Pulse - 110 irregular
Rationale:The classic signs of cardiogenic shock are low blood pressure, rapid and
weak irregular pulse, cold, clammy skin, decreased urinary output, and cerebral
hypoxia.
A 45 year old client, has no family history of breast cancer or other risk factors for this
disease. Nurse John should instruct her to have mammogram how often?
Once per year
Rationale:Yearly mammograms should begin at age 40 and continue for as long as the
woman is in good health. If health risks, such as family history, genetic tendency, or
past breast cancer, exist, more frequent examinations may be necessary.
Nurse Len refers a female client with terminal cancer to a local hospice. What is the
goal of this referral?
To provide support for the client and family in coping with terminal illness.
Rationale: Hospices provide supportive care for terminally ill clients and their families.
Hospice care doesn't focus on counseling regarding health care costs. Most client
referred to hospices have been treated for their disease without success and will
receive only palliative care in the hospice.
Nurse Oliver is assessing a client's abdomen. Which finding should the nurse report as
abnormal?
Shifting dullness over the abdomen
Rationale: Shifting dullness over the abdomen indicates ascites, an abnormal finding.
The other options are normal abdominal findings.
The nurse In-charge in labor and delivery unit administered a dose of terbutaline to a
client without checking the client's pulse. The standard that would be used to determine
if the nurse was negligent is:
,terbutaline- help to delay birth, which may give time to allow women to be transferred to
tertiary care or to complete a course of antenatal
The actions of a reasonably prudent nurse with similar education and experience.
Rationale: The standard of care is determined by the average degree of skill, care, and
diligence by nurses in similar circumstances.
Nurse Reese is teaching a female client with peripheral vascular disease about foot
care; Nurse Reese should include which instruction?
Peripheral Vascular disease-is a blood circulation disorder that causes the blood
vessels outside of your heart and brain to narrow, block, or spasm. This can happen in
your arteries or veins. PVD typically causes pain and fatigue, often in your legs, and
especially during exercise.
Avoid wearing canvas shoes.
Rationale: The client should be instructed to avoid wearing canvas shoes. Canvas
shoes cause the feet to perspire, which may, in turn, cause skin irritation and
breakdown. Both cotton and cornstarch absorb perspiration. The client should be
instructed to cut toenails straight across with nail clippers.
A newly admitted female client was diagnosed with agranulocytosis. The nurse
formulates which priority nursing diagnosis?
Agranulocytosis- also known as agranulosis or granulopenia, is an acute condition
involving a severe and dangerous lowered white blood cell count (leukopenia, most
commonly of neutrophils) and thus causing a neutropenia in the circulating blood.
Risk for infection
Rationale: Agranulocytosis is characterized by a reduced number of leukocytes
(leucopenia) and neutrophils (neutropenia) in the blood. The client is at high risk for
infection because of the decreased body defenses against microorganisms. Deficient
knowledge related to the nature of the disorder may be appropriate diagnosis but is not
the priority.
Nurse Oliver is caring for a client with impaired mobility that occurred as a result of a
stroke. The client has right sided arm and leg weakness. The nurse would suggest that
the client use which of the following assistive devices that would provide the best
stability for ambulating?
Quad cane
Rationale: Crutches and a walker can be difficult to maneuver for a client with weakness
on one side. A cane is better suited for client with weakness of the arm and leg on one
side. However, the quad cane would provide the most stability because of the structure
of the cane and because a quad cane has four legs.
A male client with a right pleural effusion noted on a chest X-ray is being prepared for
thoracentesis. The client experiences severe dizziness when sitting upright. To provide
a safe environment, the nurse assists the client to which position for the procedure?
pleural effusion- sometimes referred to as "water on the lungs," is the build-up of excess
fluid between the layers of the pleura outside the lungs.
Left side-lying with the head of the bed elevated 45 degrees.
Rationale: To facilitate removal of fluid from the chest wall, the client is positioned sitting
, at the edge of the bed leaning over the bedside table with the feet supported on a stool.
If the client is unable to sit up, the client is positioned lying in bed on the unaffected side
with the head of the bed elevated 30 to 45 degrees.
Cherry notes down ideas that were derived from the description of an investigation
written by the person who conducted it. Which type of reference source refers to this?
Primary source
Rationale: This refers to a primary source which is a direct account of the investigation
done by the investigator. In contrast to this is a secondary source, which is written by
someone other than the original researcher.
A client is admitted with multiple pressure ulcers. When developing the client's diet plan,
the nurse should include:
Pressure ulcers (also known as pressure sores or bedsores) are injuries to the skin and
underlying tissue, primarily caused by prolonged pressure on the skin. They can happen
to anyone, but usually affect people confined to bed or who sit in a chair or wheelchair
for long periods of time.
Ground beef patties
Rationale: Meat is an excellent source of complete protein, which this client needs to
repair the tissue breakdown caused by pressure ulcers. Oranges and broccoli supply
vitamin C but not protein. Ice cream supplies only some incomplete protein, making it
less helpful in tissue repair.
Ensuring that there is an informed consent on the part of the patient before a surgery is
done, illustrates the bioethical principle of:
Autonomy
Rationale: Informed consent means that the patient fully understands about the surgery,
including the risks involved and the alternative solutions. In giving consent it is done
with full knowledge and is given freely. The action of allowing the patient to decide
whether a surgery is to be done or not exemplifies the bioethical principle of autonomy.
A male client is admitted and diagnosed with acute pancreatitis after a holiday
celebration of excessive food and alcohol. Which assessment finding reflects this
diagnosis?
Pancreatitis is pathologic inflammation of the pancreas. Your pancreas sits behind your
stomach, near your small intestine.
Sudden onset of continuous epigastric and back pain
Rationale: The autodigestion of tissue by the pancreatic enzymes results in pain from
inflammation, edema, and possible hemorrhage. Continuous, unrelieved epigastric or
back pain reflects the inflammatory process in the pancreas.
Nurse Myrna is providing instructions to a nursing assistant assigned to give a bed bath
to a client who is on contact precautions. Nurse Myrna instructs the nursing assistant to
use which of the following protective items when giving bed bath?
Contact Precautions refer to infection prevention and control interventions
Gown and gloves
Rationale: Contact precautions require the use of gloves and a gown if direct client
