NCLEX PN Exam 2nd Edition - Questions & Answers with Rationale (Rated A+) | Best Update 2023

1. A nurse is caring for a client who sustained a chemical burn in his right eye. She’s preparing to irri-gate 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 conjuncti-val 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 transmis-sion of microorganisms. The solution should be direct-ed from the inner to outer canthus of the eye to pre-vent contamination of the unaffected eye. The head should be tilted toward the affected (right) eye to facil-itate 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 in-jury 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 poten-tial Cognitive level: Application 2. A nurse is caring for a client who underwent car- Answer: diac catheterization. He starts bleeding from his left femoral access site. Identify the area where the nurse should apply pressure. X Rationale: The femoral artery is punctured approxi-mately 2 inches above the access site. Nursing process step: Implementation Client needs category: Physiological integrity Client needs subcategory: Reduction of risk poten- tial Cognitive level: Application 2 FUNDAMENTALS OF NURSING 3. A nurse is preparing to leave a contact isolation room. Place the following steps in ascending chrono-logical order as to how protective wear should be re-moved. Use all the options. Remove eyewear. Remove gloves. Remove mask. Remove gown. Answer: Remove gloves. Remove mask. Remove gown. Remove eyewear. Wash hands for a minimum of 10 seconds. Wash hands for a minimum of 10 seconds. 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 conta-minants. Nursing process step: Implementation Client needs category: Safe, effective care environ-ment Client needs subcategory: Safety and infection con-trol Cognitive level: Comprehension 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 rec-tum. 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 posi-tion. Washing hands and putting on gloves are neces-sary 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 pres-sure and not by gravity. Nursing process step: Implementation Client needs category: Physiological integrity Client needs subcategory: Basic care and comfort Cognitive level: Application BASIC PHYSICAL CARE 3 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 labora-tory studies. The client has had the following intake and output during the shift: Intake: 4 oz of cranberry juice, 1⁄2 cup of oatmeal, 2 slices of toast, 8 oz of black decaffeinat-ed coffee, tuna fish sandwich, 1⁄2 cup of fruit-flavored gelatin, 1 cup of cream of mushroom soup, 6 oz. of 1% milk, 16 oz of water Output: 1,300 ml of urine How many milliliters should the nurse document as the client’s intake? __________________________ Answer: 1380 Rationale: There are 30 ml in each ounce and 240 ml in each cup. The fluid intake for this client includes 4 oz (120 ml) of cranberry juice, 8 oz (240 ml) of coffee, 1⁄2 cup (120 ml) of fruit-flavored gelatin, 1 cup (240 ml) of cream of mushroom soup, 6 oz (180 ml) of milk, and 16 oz (480 ml) of water, for a total of 1,380. Nursing process step: Implementation Client needs category: Physiological integrity Client needs subcategory: Basic care and comfort Cognitive level: Application