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Exam (elaborations)

NCLEX - PN EXAM WITH 150 QUESTIONS AND CORRECT ANSWERS 100%

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NCLEX - PN EXAM WITH 150 QUESTIONS AND CORRECT ANSWERS 100% 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 - ANSWERS 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 - ANSWERS 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 - ANSWERS 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. - ANSWERS 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. - ANSWERS 1

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