NCLEX-PN
Safety and Infection Control NCLEX PN Questions
Question 1 of 5
The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate?
Correct Answer: B
Rationale: Decreased sodium and potassium. Children with AGN who have edema, hypertension, oliguria, and azotemia have dietary restrictions limiting sodium, potassium, fluids, and protein.
Question 2 of 5
A client was just taken off the ventilator after surgery and has a nasogastric tube draining bile-colored liquids. Which nursing measure will provide the most comfort to the client?
Correct Answer: C
Rationale: Perform frequent oral care with a tooth sponge. Frequent cleansing and stimulation of the mucous membrane is important for a client with a nasogastric tube to prevent development of lesions and to promote comfort. Ice chips or mints could be contraindicated, and do not stimulate the tissue. Glycerin swabs do not cleanse since they only moisturize.
Question 3 of 5
A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to
Correct Answer: C
Rationale: accept the client's report of pain. Although all of the options above are correct, the first and most important piece of information in this client's pain assessment is what the client is telling you about the pain -- 'the client's report.'
Question 4 of 5
A client has received 2 units of whole blood today following an episode of GI bleeding. Which of the following laboratory reports would the nurse monitor most closely?
Correct Answer: B
Rationale: Hemoglobin and hematocrit. The post-transfusion hematocrit provides immediate information about red cell replacement and about continued blood loss.
Question 5 of 5
The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective?
Correct Answer: B
Rationale: Our child should brush and floss carefully after every meal.' Phenytoin causes lymphoid hyperplasia that is most noticeable in the gums. Frequent gum massage and careful attention to good oral hygiene may reduce the gingival hyperplasia.