NCLEX-PN
NCLEX Basic Care and Comfort Questions
Extract:
Question 1 of 5
Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes a serosanguious drainage on the dressing. The most appropriate intervention is to:
Correct Answer: C
Rationale: Serosanguious drainage is expected at this time. The dressing should be reinforced. Changing a new postop dressing increases the risk of infection. An abdominal binder interferes with visualization of the dressing.
Question 2 of 5
The client has dentures, including both upper and lower plates. Which technique should the nurse use to correctly perform oral hygiene for this client?
Correct Answer: C
Rationale: C: Grasping the upper plate and moving it breaks the suction that holds the plate on the roof of the client's mouth. A: Removing denture plates is a clean procedure, and sterile gloves are not necessary. B: Removing the denture plates with a foam swab to pry the plate could injure the client. D: Dentures must be removed to properly clean the client's mouth and the dentures.
Question 3 of 5
To remove a client's gown when she has an intravenous line, the nurse should:
Correct Answer: C
Rationale: Threading the bag and tubing through the gown sleeve keeps the system intact. Opening an intravenous line causes a break in a sterile system and introduces the potential for infection. Cutting a gown off is not an alternative except in an emergency. IV gowns, which open along sleeves, are widely available.
Question 4 of 5
Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes a serosanguious drainage on the dressing. The most appropriate intervention is to:
Correct Answer: C
Rationale: Serosanguious drainage is expected at this time. The dressing should be reinforced. Changing a new postop dressing increases the risk of infection. An abdominal binder interferes with visualization of the dressing.
Question 5 of 5
A client with dysphagia is ready to eat lunch. Which of these foods on the tray would be best to start with when assisting the client?
Correct Answer: B
Rationale: A client with dysphagia is at risk for aspiration. A liquid thickener will allow the LPN to assess the client's ability to swallow prior to introducing pureed or solid foods. Since Jell-O™ melts into a clear liquid, it should not be used when assessing swallowing ability.