NCLEX NCLEX Certifications NCLEX-PN Questions & Answers

• Question 461:

  Which of the following is an appropriate nursing goal for a client at risk for nutritional problems?

  A. provide oxygen

  B. promote healthy nutritional practices

  C. treat complications of malnutrition

  D. increase weight

  Correct Answer: B

  Promoting healthy nutritional practices is an appropriate nursing goal for a client at risk for nutritional

  problems.

  To provide oxygen is incorrect because it is a nursing intervention, not a goal statement.

  To treat complications of malnutrition is incorrect because it is a therapeutic treatment.

  To increase weight is incorrect because weight gain is an appropriate goal only if the client is underweight.

• Question 462:

  When making an occupied bed, it is important for the nurse to ___________.

  A. keep the bed in the low position

  B. use a bath blanket or top sheet for warmth and privacy

  C. constantly keep side rails raised on both sides

  D. move back and forth from one side to the other when adjusting the linens

  Correct Answer: B

  Using a bath blanket or top sheet keeps the client warm and provides privacy.

  Keeping the bed in the low position and working above raised side rails might strain the nurse's back.

  Continually moving back and forth to tuck and arrange linen is time-consuming and disorganized.

• Question 463:

  To remove a client's gown when she has an intravenous line, the nurse should __________.

  A. temporarily disconnect the intravenous tubing at a point close to the client and thread it through the gown

  B. cut the gown with scissors

  C. thread the bag and tubing through the gown sleeve, keeping the line intact

  D. temporarily disconnect the tubing from the intravenous container and thread it through the gown

  Correct Answer: C

  Threading the bag and tubing through the gown sleeve keeps the system intact.

  Opening an intravenous line causes a break in a sterile system and introduces the potential for infection.

  Cutting a gown off is not an alternative except in an emergency.

  IV gowns, which open along sleeves, are widely available.

• Question 464:

  To remove hard contact lenses from an unresponsive client, the nurse should __________.

  A. gently irrigate the eye with an irrigating solution from the inner canthus outward

  B. grasp the lens with a gentle pinching motion

  C. don sterile gloves before attempting the procedure

  D. ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens

  Correct Answer: D

  To remove hard contact lenses, the upper and lower eyelids are gently maneuvered to help loosen the

  lens and slide it out of the eye. The lens must be situated on the cornea, not the sclera, before removal.

  An attempt to grasp a hard lens might result in a scratch on the cornea.

  Clean gloves are an option if drainage is present.

• Question 465:

  A client turns her ankle. She is diagnosed as having a Pulled Ligament.

  This should be documented as a __________.

  A. sprain

  B. strain

  C. subluxation

  D. distoration

  Correct Answer: B

  A strain is excessive stretching of a ligament.

  A sprain involves a twisting motion involving muscles.

• Question 466:

  A client is complaining of difficulty walking secondary to a mass in the foot.

  The nurse should document this finding as __________.

  A. plantar fasciitis

  B. hallux valgus

  C. hammertoe

  D. Morton's neuroma

  Correct Answer: D

  Morton's neuroma is a small mass or tumor in a digital nerve of the foot.

  Hallux valgus is referred to in lay terms as abunion.

  Hammertoe is where one toe is cocked up over another toe.

  Plantar fasciitis is an inflammation of, or pain in, the arch of the foot.

• Question 467:

  A client who is immobilized secondary to traction is complaining of constipation.

  Which of the following medications should the nurse expect to be ordered?

  A. Advil

  B. Anasaid

  C. Clinocil

  D. Colace

  Correct Answer: D

  Colace is a stool softener that acts by pulling more water into the bowel lumen, making the stool soft and easier to evacuate.

• Question 468:

  Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes a serosanguious drainage on the dressing.

  The most appropriate intervention is to __________.

  A. notify the physician of the drainage

  B. change the dressing

  C. reinforce the dressing

  D. apply an abdominal binder

  Correct Answer: C

  Serosanguious drainage is expected at this time. The dressing should be reinforced.

  Changing a new postop dressing increases the risk of infection.

  An abdominal binder interferes with visualization of the dressing.

• Question 469:

  A client with an ileus is placed on intestinal tube suction.

  Which of the following electrolytes is lost with intestinal suction?

  A. calcium

  B. magnesium

  C. potassium

  D. sodium chloride

  Correct Answer: D

  Duodenal intestinal fluid is rich in K+, NA+, and bicarbonate.

  Suctioning to remove excess fluids decreases the client's K+ and NA+ levels.

• Question 470:

  A client with dumping syndrome should ___________ while a client with GERD should ___________.

  A. sit up 1 hour after meals; lie flat 30 minutes after meals

  B. lie down 1 hour after eating; sit up at least 30 minutes after eating

  C. sit up after meals; sit up after meals

  D. lie down after meals; lie down after meals

  Correct Answer: B

  Clients with dumping syndrome should lie down after eating to decrease dumping syndrome. GERD clients should sit up to prevent backflow of acid into the esophagus.