VATI GREENLIGHT EXAM: COMPREHENSIVE NCLEX-RN COMPLETE REVIEW QUESTION BANK 200 Practice Questions with Verified Answers & Rationales

VATI GREENLIGHT EXAM: COMPREHENSIVE NCLEX-RN COMPLETE REVIEW QUESTION BANK 200 Practice Questions with Verified Answers & Rationales SECTION 1: FUNDAMENTALS OF NURSING (Questions 1-25) ________________________________________ 1. A nurse is assessing a client's peripheral edema. Which of the following techniques should the nurse use to accurately evaluate pitting edema? A. Press firmly against the edematous area for 5 seconds and observe the depth of indentation B. Gently palpate the skin and note the presence of tautness C. Measure the circumference of the affected extremity D. Assess skin turgor by pinching the skin over the sternum Answer: A Pressing firmly against the edematous area for 5 seconds allows the nurse to assess pitting edema by measuring the depth of indentation (graded 1+ to 4+). Gentle palpation does not provide accurate measurement. Circumference measurement tracks changes but does not evaluate pitting. Skin turgor assessment over the sternum evaluates dehydration, not edema. ________________________________________ 2. A nurse is providing oral hygiene to an unconscious client. Which of the following actions should the nurse take to prevent aspiration? A. Place the client in a supine position with the head flat B. Use a toothbrush to vigorously clean the teeth C. Position the client in a side-lying position with the head turned to the side D. Use a large amount of mouthwash to rinse the oral cavity Answer: C Positioning the client in a side-lying position with the head turned to the side allows fluids to drain from the mouth by gravity and reduces the risk of aspiration. Supine positioning increases aspiration risk. Vigorous brushing can damage oral tissues. Large amounts of mouthwash increase aspiration risk. ________________________________________ 3. A nurse is preparing to insert a nasogastric tube for gastric decompression. Which of the following actions should the nurse take first? A. Measure the length of the tube from the nose to the earlobe to the xiphoid process B. Apply lubricant to the distal end of the tube C. Place the client in a high Fowler's position D. Assess the client's gag reflex and ability to swallow Answer: C The nurse should first place the client in a high Fowler's position to facilitate tube insertion and reduce the risk of aspiration. While measuring, lubricating, and assessing gag reflex are all important steps, positioning the client is the priority initial action for safety and optimal insertion technique. ________________________________________ 4. A nurse is caring for a client who has an order for continuous bladder irrigation following a transurethral resection of the prostate. Which of the following actions should the nurse take? A. Monitor the output for blood clots and report large clots immediately B. Maintain the irrigation solution at room temperature only C. Clamp the drainage tubing for 30 minutes after each irrigation D. Discontinue irrigation if the output is less than the input Answer: A Monitoring output for blood clots is essential as large clots can indicate hemorrhage or obstruction. Irrigation solution should be at room temperature, but this is not the priority action. Clamping drainage tubing is contraindicated. Discontinuing irrigation when output is less than input may indicate obstruction requiring intervention, not discontinuation. ________________________________________ 5. A nurse is reinforcing teaching with a client who has a new colostomy. Which of the following statements indicates the client understands the teaching? A. I will change the pouch every day to prevent skin breakdown B. I should eat foods high in fiber to reduce odor C. I will empty the pouch when it is one-third to one-half full D. I can expect the stoma to be large and purple in color Answer: C Emptying the pouch when it is one-third to one-half full prevents leakage and pouch separation. Pouches should be changed every 3-7 days or when leaking, not daily. High-fiber foods increase output, not reduce odor. A healthy stoma should be pink/red and moist, not purple (which indicates ischemia). ________________________________________ 6. A nurse is performing a sterile dressing change. Which of the following actions demonstrates proper sterile technique? A. The nurse places the sterile field at waist level B. The nurse opens the sterile package away from the body C. The nurse reaches over the sterile field to retrieve supplies D. The nurse wears sterile gloves but does not use sterile drapes Answer: A Placing the sterile field at waist level maintains sterility as the field is within the nurse's line of sight. Opening sterile packages away from the body prevents contamination, but this is not the demonstration of sterile field maintenance. Reaching over the sterile field contaminates it. Sterile drapes should be used to create an adequate sterile field. ________________________________________ 7. A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take? A. Position the client in a left lateral Sims' position B. Administer the enema solution at a temperature of 120°F C. Insert the rectal tube 10-15 cm (4-6 inches) D. Place the enema bag 30 cm (12 inches) above the client's hip Answer: A The left lateral Sims' position allows the enema solution to flow into the sigmoid and descending colon by gravity, following the natural anatomical path. Solution should be at 105-110°F (not 120°F). Insertion depth for adults is 7.5-10 cm (3-4 inches), not 10-15 cm. The bag should be 45 cm (18 inches) above the client's hip. ________________________________________ 8. A nurse is caring for a client who has a stage 3 pressure injury. Which of the following wound characteristics would the nurse expect to observe? A. Full-thickness tissue loss with visible bone and tendon B. Partial-thickness skin loss with exposed dermis C. Full-thickness tissue loss with visible subcutaneous fat but not bone D. Non-blanchable erythema of intact skin Answer: C Stage 3 pressure injuries involve full-thickness tissue loss with visible subcutaneous fat, but bone, tendon, and muscle are not exposed. Visible bone/tendon indicates stage 4. Partial-thickness loss indicates stage 2. Non-blanchable erythema indicates stage 1. ________________________________________ 9. A nurse is preparing to transfer a client from a bed to a chair using a mechanical lift. Which of the following actions should the nurse take? A. Place the lift sling so the client's arms are inside the sling B. Position the client in a semi-Fowler's position during transfer C. Ensure the client's weight is within the lift's weight capacity D. Use the lift only with the client's bilateral grasp intact Answer: C Ensuring the client's weight is within the lift's weight capacity is essential for safety and preventing equipment failure. Arms should be outside the sling, not inside. The client should be supine during transfer, not semi-Fowler's. The lift can be used regardless of grasp strength.