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NCLEX PN NGN Exam 2nd Edition Test Bank 250 New Generation Question & Answers

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NCLEX PN 2nd Test Bank 250 New Generation Question & Answers P A R T O N E – Fundamentals of Nursing Basic physical care 1. A nurse is caring for a client who sustained a chemical burn in his right eye. She’s preparing to irrigate the eye with sterile normal saline solution. Which steps ...

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  • July 11, 2022
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  • 2021/2022
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  • nclex pn 2nd edition test bank 250 new generation question amp answers davidjamin19gmailcom nclex pn 2nd test bank 250 new generation question amp answers p a r t o n e – fundamentals of nursin

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NCLEX PN 2nd Edition Test Bank
250 New Generation Question & Answers






, NCLEX PN 2nd Test Bank
250 New Generation Question & Answers
P A R T O N E – Fundamentals of Nursing
Basic physical care
1. A nurse is caring for a client who sustained a
chemical burn in his right eye. She’s preparing to irrigate
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 conjunctival
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 transmission
of microorganisms. The solution should be directed
from the inner to outer canthus of the eye to prevent
contamination of the unaffected eye. The head
should be tilted toward the affected (right) eye to facilitate
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 injury
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 potential
Cognitive level: Application
2. A nurse is caring for a client who underwent cardiac
catheterization. He starts bleeding from his left
femoral access site. Identify the area where the nurse
should apply pressure.
Answer:

,Rationale: The femoral artery is punctured approximately
2 inches above the access site.

, Nursing process step: Implementation
Client needs category: Physiological integrity
Client needs subcategory: Reduction of risk potential
Cognitive level: Application
3. A nurse is preparing to leave a contact isolation
room. Place the following steps in ascending chronological
order as to how protective wear should be removed.
Use all the options.
Answer:
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 contaminants.
Nursing process step: Implementation
Client needs category: Safe, effective care environment
Client needs subcategory: Safety and infection control
Cognitive level: Comprehension
B A S I C P H Y S I C A L C AR E 3
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 rectum.
_ 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 position.
Washing hands and putting on gloves are necessary
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 pressure
and not by gravity.

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