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NEXT GEN NCLEX -PN FINAL EXAM UPDATED QUESTIONS AND WELL EXPLAINED SOLUTIONS COMPLETE VERSION BEST FOR STUDY VERIFIED 100% GRADED A+ NEWEST£15.86
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NEXT GEN NCLEX -PN FINAL EXAM
UPDATED QUESTIONS AND WELL EXPLAINED
SOLUTIONS COMPLETE VERSION BEST FOR STUDY
VERIFIED 100% GRADED A+ NEWESTNEXT GEN NCLEX -PN FINAL EXAM
UPDATED QUESTIONS AND WELL EXPLAINED
SOLUTIONS COMPLETE VERSION BEST FOR STUDY
VERIFIED 100% GRADED A+ NEWESTNEXT GEN ...
NEXT GEN NCLEX -PN FINAL EXAM 2023 -2024
UPDATED QUESTIONS AND WELL EXPLAINED
SOLUTIONS COMPLETE VERSION BEST FOR STUDY
VERIFIED 100% \\GRADED A+ NEWEST
The nurse is changing a central line dressing and has just finished
applying the chlorhexidine skin prep. Which of the following is the
priority rationale for allowing the skin prep to dry before applying the
Tegaderm dressing?
A .to prevent moisture from building u under the dressing
B. To allow for the antimicrobial action of the chlorhexidine to any skin
flora
C .To prevent wrinkling of the Tegaderm
D .To allow the dressing to stick to the skin better
Answers Explanation ;
Allowing for the antimicrobial action of the chlorhexidine to kill any
skin flora is the priority. The chlorhexidine solution works best if
allowed to dry, allowing the antibacterial action to work in the
prevention of infection. Allowing the dressing to stick to the skin is not
the priority rationale. While it may be true that it will help keep the
dressing in place, it is not the primary reason. Prevention of wrinkling
of the Tegaderm is not the priority rationale. Wrinkling may occur with
or without moisture; it is dependent on the technique of the nurse
,Page 2 of 92
applying the dressing. Preventing moisture from building up under the
dressing is not the priority rationale because the Tegaderm is
semipermeable and will allow for drying to occur.
The nurse is caring for a client in phase two of recovery .The client will
be discharged home once they have recovered well enough .The nurse
would be concerned seeing which of these findings ?
A .The client oxygen saturation is 91 % on room air
B .the surgical dressing is saturated with serosanguinous drainage
C . A scant amount of the bloody drainage has seeped through the
surgical dressing
D . The clients pain level has not decreased 5 min after intravenous
medication
Answers Explanation ;
The surgical dressing is saturated with serosanguinous drainage is the
correct answer. Bloody (sanguineous) drainage is expected after
surgery, but the dressing should not be soaked in fluid. Either the client
is actively bleeding, or a drainage device may not be in place. A scant
amount of bloody drainage has seeped through the surgical dressing is
not the correct answer. Sanguineous (bloody) drainage is expected
immediately after surgery. The nurse should mark the borders of the
drainage visible to monitor increasing drainage. The client's pain level
has not decreased 5 minutes after intravenous medication is not the
correct answer. The post-operative area uses low-dose intravenous
analgesia. It works within minutes and lasts less than an hour. If the pain
is not managed immediately, the client needs more pain medicine or
needs more time for it to work. The client's oxygen saturation is 91%
on room air is not the correct answer. It does depend on what type of
surgery the client had, what comorbidities the client has, and what their
baseline O2 saturations were, but the parameter for recovery is a
,Page 3 of 92
saturation over 90%. This does meet that parameter. The nurse needs
to check that this is in line with that measurement.
Client with peripheral arterial disease (PAD) is at risk for insufficient
vascular perfusion to their lower extremities. Which of the following
assessments should the nurse prioritize?
A . heart rate
B .Pedal pulses
C Respiratory rate
( D) Blood glucose level
Answers Explanation ;
Presence of pedal pulses is the correct answer. Clients with PAD have
decreased blood flow to the lower extremities, making them at risk for
insufficient vascular perfusion. Checking for the presence of pedal
pulses can provide information about the perfusion status of the feet.
Heart rate is incorrect because although it is an important vital sign, it
does not provide specific information about the perfusion status of the
lower extremities. Respiratory rate is incorrect because although it is
an important assessment, it does not provide specific information about
the perfusion status of the lower extremities. Blood glucose level is
incorrect because although it is an important laboratory test, it does
not provide specific information about the perfusion status of the lower
extremities.
The client has a history of chronic kidney disease and is being treated
with hemodialysis. End stage renal disease can produce varied clinical
manifestations.
, Page 4 of 92
Which of the following signs and symptoms can be attributed to the
client's chronic kidney disease? Select all the apply.
( a )muffled heart tones
(b) hypotension with narrowed pulse pressure
( C)crackles in bilateral lung bases
(d) generalized pollar with sratches noted to bilateral upper extremities
( e) pitting edema in both legs
(f) distended neck veins
(g)tachycardia
Answers Explanation ;
he client experiencing generalized pallor with scratches noted to
bilateral upper extremities is indicative of chronic kidney disease.
Chronic kidney disease can cause generalized pallor because many
clients are anemic, the kidneys produce erythropoietin in insufficient
amounts which leads to the bone marrow producing fewer red blood
cells over time causing anemia. Scratches to the body are common due
to itching caused by the presence of toxins in the blood that the
kidneys cannot filter out. The client experiencing crackles in bilateral
bases is indicative of chronic kidney disease. Crackles in bilateral bases
are a result of fluid volume overload that occurs as a result of very low
or no urinary output in end-stage renal disease, the body must rely on
dialysis to remove excess fluid from the body so if the client misses a
dialysis treatment or drinks too much fluid in between treatments fluid
volume overload can occur very quickly. The client experiencing
distended neck veins is indicative of chronic kidney disease. Distended
neck veins are also a result of fluid volume overload as fluid overload
occurs due to the result of very low or no urinary output in end-stage
renal disease. The body must rely on dialysis to remove excess fluid
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