NCLEX-RN
Planning Questions
Question 1 of 5
The nurse is caring for a client who is receiving total parenteral nutrition through a central venous catheter. Which action should the nurse plan to implement to decrease the risk of infection in this client?
Correct Answer: D
Rationale: Sterile technique is vital during dressing changes of a central venous catheter (CV
C). CVCs are large-bore catheters that can serve as a direct-entry point for microorganisms into the heart and circulatory system. Using aseptic technique helps avoid catheter-related infections by preventing the introduction of potential pathogens to the site. Although the remaining options are reasonable nursing interventions for a client with a CVC, none of them prevents infection. Options 1 and 3 are assessment methods, and option 2 is implemented after the confirmation of an existing infection.
Question 2 of 5
The nurse creates a plan of care for a client with a spica cast that covers a lower extremity. Which action should the nurse include in the plan of care to promote bowel elimination?
Correct Answer: D
Rationale: A client with a spica cast (body cast) that covers a lower extremity cannot bend at the hips to sit up. A low-profile bedpan or fracture pan is designed for use by clients with body or leg casts and for clients who have difficulty raising the hips to use a standard bedpan; therefore, using a commode or the bathroom is contraindicated. Daily enemas are not a part of routine care.
Question 3 of 5
The nurse is caring for a postpartum client with thromboembolytic disease. Which intervention is most important to include when planning care to prevent the complication of pulmonary embolism?
Correct Answer: D
Rationale: The purposes of anticoagulant therapy for the treatment of thromboembolytic disease are to prevent the formation of a clot and to prevent a clot from moving to another area, thus preventing pulmonary embolism. Although the remaining options may be implemented for a client with thromboembolytic disease, the correct option will specifically assist in the prevention of pulmonary embolism.
Question 4 of 5
The student nurse is listening to a lecture on serum electrolyte levels and the use of isotonic solutions. Which statement by the student nurse indicates that the teaching has been effective?
Correct Answer: C
Rationale: Five percent dextrose in water is an isotonic solution, which means that the osmolality of this solution matches normal body fluids. Other examples of isotonic fluids include 0.9% sodium chloride solution (normal saline) and lactated Ringer's solution. Ten percent dextrose in water and 3% sodium chloride solution are hypertonic solutions, and 0.45% sodium chloride solution is hypotonic.
Question 5 of 5
The nurse is admitting a client who recently underwent a bilateral adrenalectomy. Which intervention is essential for the nurse to include in the client's plan of care?
Correct Answer: D
Rationale: Adrenalectomy can lead to adrenal insufficiency. Adrenal hormones are essential to maintaining homeostasis in response to stressors. None of the remaining options are essential interventions specific to this client's problem.