NCLEX-PN
Free NCLEX-PN Practice Questions Questions
Extract:
The maximum safe height at which the container of fluid can be held when administering an enema is:
Question 1 of 5
The maximum safe height at which the container of fluid can be held when administering an enema is:
Correct Answer: C
Rationale: 45 cm (18 inches) ensures safe pressure to avoid bowel injury during an enema.
Extract:
Question 2 of 5
The nurse is caring for a preschool-aged child admitted with a diagnosis of suspected child abuse. During painful procedures, the child remains quiet and watchful. When planning the care of a victim of child abuse, the nurse should give priority to:
Correct Answer: B
Rationale: Assigning a consistent caregiver will best meet the child's need for safety and security. Playtime will be therapeutic for the child, but it does not have to be with same-age children, so answer A is incorrect. Answer C is too threatening to the child who has been abused, so it is incorrect. Answer D does not allow the child the chance to respond in an expected way, so it is incorrect.
Question 3 of 5
The nurse must irrigate a gaping abdominal incision with sterile normal saline, using a piston syringe. How should the nurse proceed?
Correct Answer: A
Rationale:
To wash away tissue debris and drainage effectively, the nurse should irrigate the wound until the solution becomes clear or all of the solution has been used. After the irrigation, the nurse should dry the area around the wound; moistening it promotes microorganism growth and skin irritation. When the area is dry, the nurse should apply a sterile dressing, rather than a wet-to-dry dressing. The nurse always should instill the irrigating solution gently; rapid or forceful instillation can damage tissues.
Question 4 of 5
During a first aid class, the nurse instructs clients on the emergency care of second-degree burns. The nurse knows that which of the following interventions for second-degree burns of the chest and arms will BEST prevent infection?
Correct Answer: B
Rationale: After extinguishing the fire, removing clothing and wrapping the victim in a clean sheet prevents contamination and infection in second-degree burns. Soap or ointments (A,
C) are contraindicated in emergencies, and delaying action (
D) increases infection risk.
Question 5 of 5
A client diagnosed with Borderline Personality Disorder frequently attempts to burn herself. The best intervention to facilitate behavior change is:
Correct Answer: B
Rationale: The challenge when intervening with clients who might harm themselves is to maintain client safety while facilitating behavior change. Enlisting the client to identify the triggers for self-harm makes the client an active participant in treatment.