NCLEX Basic Care and Comfort

Extract:

Question 1 of 5

A nurse assesses a 83 year-old female's venous ulcer for the second time that is located near the right medial malleolus. The wound is exhibiting purulent drainage and the patient has limited mobility in her home. Which of the options is the best course of action?

Correct Answer: A

Rationale: A determination of arterial blood flow should be made, prior to encouraging increased activity, or notifying additional team members.

Question 2 of 5

The client voided 300 mL after having an indwelling urinary catheter removed six hours ago. A bladder scan immediately after the void showed that the client has a postvoid residual (PVR) volume of 250 mL. What should the nurse conclude from this finding?

A. This is an expected finding following catheter removal. B. The client's bladder function is approximately 50% of normal. C. The bladder scan was not done within 20 minutes of voiding. D. The PVR volume is evidence of incomplete bladder emptying.

Correct Answer: D

Rationale: D: A PVR of 250 mL indicates incomplete bladder emptying, as normal PVR is less than 50 mL. A: High PVR is not expected. B: PVR doesn't quantify bladder function percentage. C: No evidence suggests timing was incorrect.

Question 3 of 5

The NA tells the nurse that the unit's small-adult BP cuff cannot be found and that the client's arm is too small to use a regular adult-sized cuff. Which direction should the nurse give to the NA?

A. Document the other vital signs and note that the proper-fitting BP cuff is not available. B. Go to another nursing unit to obtain their small-adult BP cuff, and take the client's BP. C. Use the regular-sized BP cuff and add 10 to the diastolic and systolic BP readings. D. If the cuff closes around the arm, take the client's BP using the regular adult cuff.

Correct Answer: B

Rationale: B: A correct-sized cuff ensures accurate BP readings. A: Omitting BP is inappropriate. C: Adjusting readings is inaccurate. D: A too-large cuff gives falsely low readings.

Question 4 of 5

The method of splinting is always dictated by:

A. Location of the injury and whether it is open or closed B. The severity of the client's condition and the priority decision C. The number of available rescuers and the type of splints D. All of the above

Correct Answer: B

Rationale: The severity of the client's condition and priority decision dictate splinting to ensure stabilization and prevent further injury, taking precedence over location or resources.

Question 5 of 5

The postoperative male client has been unable to urinate into the urinal while lying in bed. Which interventions are appropriate to promote voiding for this client who is to be discharged home within a few hours? Select all that apply.

A. Have the client apply an external condom catheter while lying flat in bed B. Assist the client to stand at the bedside to attempt to urinate in a urinal. C. Administer a prescribed analgesic if the client is experiencing pain. D. Turn on running water so it is heard while the client attempts to void. E. Ask the client to imagine being at home and voiding in his own bathroom.

Correct Answer: B,C,D,E

Rationale: B: Standing mimics normal voiding position. C: Pain relief aids relaxation for voiding. D: Running water stimulates the voiding reflex. E: Guided imagery promotes relaxation. A: Condom catheters manage incontinence, not promote voiding.

NCLEX Basic Care and Comfort | Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN