NCLEX NCLEX Certifications NCLEX-PN Questions & Answers

• Question 441:

  Perineal care to a female client by the nurse can be performed ___________.

  A. without gloves, pouring water from a sterile bottle

  B. without gloves, having the client perform all care

  C. with gloves, washing the perineal area from front to back

  D. with gloves, washing the perineal area from back to front

  Correct Answer: C

  Gloves should always be worn, and the perineal area should be washed with a washcloth from front to back. This method prevents E. coli and other bacteria from being swept into the urethra. The procedure should be performed and explained in a private area with all equipment gathered first.

• Question 442:

  Accurate documentation of assessment findings regarding pressure ulcers is very important because ___________.

  A. the law requires the nurse to document lesions

  B. the hospital requires the nurse to document lesions

  C. the physician requires the nurse to document lesions

  D. the nursing assessment of ulcers is a standard of nursing practice

  Correct Answer: D

  Documentation of assessments by the nurse promotes continuity of care and helps prevent further

  progression of the ulcer.

• Question 443:

  Pressure ulcers usually occur ___________.

  A. when clients are left in one position in bed for extended periods of time

  B. when clients are underweight

  C. when clients are overweight

  D. only in underweight and overweight clients

  Correct Answer: A

  Pressure ulcers usually occur over bony prominences and are caused by decreased circulation. The client who is left in one position in bed for extended periods of time is more prone to decreased circulation to an area of the body and to acquiring a pressure ulcer.

• Question 444:

  The nurse is transferring a client from a wheelchair to the bed. Which is the correct procedure?

  A. Pull the client toward you, and pivot him on the unaffected limb.

  B. Pull the client toward you, and pivot him on the affected limb.

  C. Push the client toward the bed, and pivot him on the affected limb.

  D. Stand the client on both legs, and push him toward the bed.

  Correct Answer: A

  Pulling the client toward the nurse lowers the workload force.

  Pivoting on the unaffected limb offers strength to support the affected limb while pivoting to the bed.

• Question 445:

  Pulling is easier than pushing.

  So pulling a client rather than pushing him or her has which of the following advantages?

  A. reduces workload

  B. decreases opposition from gravity

  C. maintains stability

  D. prevents muscle strain

  Correct Answer: A

  Pulling an object works with gravitational force not opposing it, lowering risk of muscle strain.

• Question 446:

  A client is having problems with her ankles.

  To assess her ankles' ROM, which ROM exercises should the nurse have her perform?

  A. flexion, extension, hyperextension

  B. flexion, extension, abduction, adduction

  C. external rotation, internal rotation

  D. extension, flexion, inversion, eversion

  Correct Answer: D

  Moving a joint through the full range of motion identifies limitation of movement.

• Question 447:

  A client has a nasogastric (NG) tube in place following abdominal surgery. The purpose of this tube immediately following surgery is to ___________.

  A. simplify medication administration

  B. measure accurate input and output

  C. prevent accumulation of fluids and gas

  D. facilitate collection of specimens

  Correct Answer: C

  Immediately postop abdominal surgery, the NG tube keeps the stomach decompressed to prevent surgical-site disruption and fluid loss through vomiting.

• Question 448:

  A client with major head trauma is receiving bolus enteral feeding. The most important nursing order for this client is ___________.

  A. measure intake and output

  B. check albumin level

  C. monitor glucose levels

  D. increase enteral feeding

  Correct Answer: A

  It is important to measure intake (I) and output (O), which should be approximately equal.

  Enteral feedings are hyperosmotic agents pulling fluid from cells into the vascular bed.

  Water given before feeding presents a hyperosmotic diuresis. I and O measures assess fluid balance.

• Question 449:

  In evaluating the lab work of a client in a hepatic coma, which of the following lab tests is most important?

  A. blood urea nitrogen

  B. serum calcium

  C. serum ammonia

  D. serum creatinine

  Correct Answer: C

  When a client is in a hepatic coma, he is in live liver failure.

  The liver can no longer metabolize amino acids completely, thus ammonia levels increase causing brain-

  tissue irritation.

• Question 450:

  Hazards of improper splinting include ___________.

  A. aggravation of a bone or joint injury

  B. reduced distal circulation

  C. delay in transport of a client with a lifethreatening injury

  D. all of the above

  Correct Answer: D

  Hazards of improper splinting include aggravation of a bone or joint injury, reduced distal circulation, and delay in transport of a client with a life-threatening injury.