NCLEX PN TESTBANK Contains 862 Questions and
Answers
The critical care nurse is caring for a client with a subclavian central line catheter.
The nurse knows that a specific central-line bundle was developed to reduce the
client's risk for developing a catheter-related bloodstream infection (CLABSI). The
interventions include which essential actions? Select all that apply.
1.
Strict hand washing
2.
Daily dressing change
3.
Betadine skin antisepsis
4.
Optimal catheter site selection
5.
Strict sterile technique with maximal barrier precautions during placement
6.
Infection control primary health care provider as a member of the client's health
care team - ANSWER: 1, 4, 5
The nurse caring for a Chinese-American client plans to use communication
according to Chinese-American cultural beliefs and practices. Which techniques are
considered disrespectful in the Chinese-American's view of communication? Select
all that apply.
1.
Sitting side-by-side
2.
Maintaining eye contact
3.
Closing the conversation abruptly
4.
Touching the opposite sex in public
5.
Allowing silent pauses during conversation - ANSWER: 2, 3, 4
,he nurse is assigned to care for a client with a diagnosis of detached retina. Which
findings would indicate that bleeding has occurred as a result of retinal detachment?
Select all that apply.
1.
Total loss of vision
2.
Vision may be cloudy
3.
A reddened conjunctiva
4.
A sudden sharp pain in the eye
5.
Complaints of a burst of black spots or floaters
6.
Vision is clear straight ahead but not to the right - ANSWER: 2, 5
The nurse admits a client who has seizure precautions prescribed. The client has a
seizure just after the nurse has implemented the precautions. Which actions should
the nurse take? Select all that apply.
1.
Time the start and stop of the seizure.
2.
Apply oxygen at 2L with nasal cannula.
3.
Turn the client to the side and do not restrain.
4.
Note the distinguishing characteristics of the seizure.
5.
Use a padded tongue blade to avoid tongue injury.
6.
Turn on the suction machine with oral catheter. - ANSWER: 1, 2, 3, 4, 6
A primary health care provider (PHCP) has written a prescription for a preoperative
client to have "enemas until clear." The nurse has administered three enemas and
the client is still passing brown liquid stool. Which action should the nurse take next?
, 1.
Notify the primary health care provider.
2.
Continue to administer the enemas until the stool is clear.
3.
Encourage the client to drink clear liquids and administer another enema in 1 hour.
4.
Wait 30 minutes, check the client's electrolyte levels, and then administer another
enema. - ANSWER: 1
The nurse reviews the client's health record and notes that based on Leopold's
maneuvers, the fetus is in a cephalic presentation. Which findings while performing
Leopold's maneuvers support the identification of a cephalic presentation? Select all
that apply.
1.
Small parts are located on the left side of the uterus.
2.
Small parts are located on the right side of the uterus.
3.
A round hard ballottable shape is located in the fundus.
4.
A round hard ballottable shape is located just above the symphysis pubis.
5.
A soft, irregular non-ballottable shape is located just above the symphysis pubis. -
ANSWER: 1, 2, 5
he nurse is assigned to assist the primary health care provider (PHCP) with the
removal of a chest tube. Which interventions should the nurse anticipate performing
during this process? Select all that apply.
1.
Reinforce instructions to breathe deeply while the tube is removed.
2.
Cover the site with an occlusive dressing after the tube is removed.
3.
Clamp the chest tube near the insertion site just before the removal.
Answers
The critical care nurse is caring for a client with a subclavian central line catheter.
The nurse knows that a specific central-line bundle was developed to reduce the
client's risk for developing a catheter-related bloodstream infection (CLABSI). The
interventions include which essential actions? Select all that apply.
1.
Strict hand washing
2.
Daily dressing change
3.
Betadine skin antisepsis
4.
Optimal catheter site selection
5.
Strict sterile technique with maximal barrier precautions during placement
6.
Infection control primary health care provider as a member of the client's health
care team - ANSWER: 1, 4, 5
The nurse caring for a Chinese-American client plans to use communication
according to Chinese-American cultural beliefs and practices. Which techniques are
considered disrespectful in the Chinese-American's view of communication? Select
all that apply.
1.
Sitting side-by-side
2.
Maintaining eye contact
3.
Closing the conversation abruptly
4.
Touching the opposite sex in public
5.
Allowing silent pauses during conversation - ANSWER: 2, 3, 4
,he nurse is assigned to care for a client with a diagnosis of detached retina. Which
findings would indicate that bleeding has occurred as a result of retinal detachment?
Select all that apply.
1.
Total loss of vision
2.
Vision may be cloudy
3.
A reddened conjunctiva
4.
A sudden sharp pain in the eye
5.
Complaints of a burst of black spots or floaters
6.
Vision is clear straight ahead but not to the right - ANSWER: 2, 5
The nurse admits a client who has seizure precautions prescribed. The client has a
seizure just after the nurse has implemented the precautions. Which actions should
the nurse take? Select all that apply.
1.
Time the start and stop of the seizure.
2.
Apply oxygen at 2L with nasal cannula.
3.
Turn the client to the side and do not restrain.
4.
Note the distinguishing characteristics of the seizure.
5.
Use a padded tongue blade to avoid tongue injury.
6.
Turn on the suction machine with oral catheter. - ANSWER: 1, 2, 3, 4, 6
A primary health care provider (PHCP) has written a prescription for a preoperative
client to have "enemas until clear." The nurse has administered three enemas and
the client is still passing brown liquid stool. Which action should the nurse take next?
, 1.
Notify the primary health care provider.
2.
Continue to administer the enemas until the stool is clear.
3.
Encourage the client to drink clear liquids and administer another enema in 1 hour.
4.
Wait 30 minutes, check the client's electrolyte levels, and then administer another
enema. - ANSWER: 1
The nurse reviews the client's health record and notes that based on Leopold's
maneuvers, the fetus is in a cephalic presentation. Which findings while performing
Leopold's maneuvers support the identification of a cephalic presentation? Select all
that apply.
1.
Small parts are located on the left side of the uterus.
2.
Small parts are located on the right side of the uterus.
3.
A round hard ballottable shape is located in the fundus.
4.
A round hard ballottable shape is located just above the symphysis pubis.
5.
A soft, irregular non-ballottable shape is located just above the symphysis pubis. -
ANSWER: 1, 2, 5
he nurse is assigned to assist the primary health care provider (PHCP) with the
removal of a chest tube. Which interventions should the nurse anticipate performing
during this process? Select all that apply.
1.
Reinforce instructions to breathe deeply while the tube is removed.
2.
Cover the site with an occlusive dressing after the tube is removed.
3.
Clamp the chest tube near the insertion site just before the removal.
