NSG 3100 NCLEX Questions Unit 1

NSG 3100 NCLEX Questions Unit 1 1. The nurse is preparing to provide morning care to a client. What should the nurse explain to the client as the reason for a daily bath? 1. Assess skin integrity 2. Develop a nurse/client relationship 3. Moisturize the skin 4. Stimulate circulation Correct Answer: 4 Rationale 1: Giving a bath to a client will allow the nurse to assess the skin but this is not the most important purpose. Rationale 2: Giving a bath to a client will allow the nurse to develop a nurse/client relationship but this is not the most important purpose. Rationale 3: Giving a bath to a client will allow the nurse to moisturize the skin but this is not the most important purpose. Rationale 4: The three major reasons for a bath are to remove waste products such as perspiration, stimulate circulation, and refresh the client. 2. The nurse is preparing to bath a client on the first postoperative day. Which nursing intervention should take priority? 1. Apply lotion to the extremities. 2. Change the water when it becomes cold. 3. Raise side rails when gathering supplies. 4. Remove the soiled dressing during the bath. Correct Answer: 3 Rationale 1: Applying lotion to the skin would be performed before or after, not during, the bath. Rationale 2: Changing the water needs to be done before it becomes cold, but it is not a priority. Rationale 3: Raising the side rails would take priority when planning care. This is a safety issue, and safety is second on Maslow’s Hierarchy of Needs. The client is only 1 day postop and may still be sedated, posing a risk for a potential fall. Rationale 4: A dressing change would be performed before or after, not during, the bath and only with a doctors order. 3. The nurse identifies the diagnosis Self-Care Deficit related to cognitive impairment as appropriate for a client. What should the nurse select as an expected outcome for this client? 1. The client will be able to name the staff that works on the day shift. 2. The client will eliminate safety hazards in her environment. 3. The client, with supervision, will brush her teeth. 4. The nurse will stress the importance of adequate fluid intake. Correct Answer: 3 1 This study source was downloaded by from CourseH on :46:04 GMT -05:00