NCLEX-PN
Basic Care and Comfort NCLEX PN Questions Questions
Extract:
Question 1 of 5
The LPN is preparing to ambulate a client post total knee replacement. Which of the following actions should the nurse perform prior to ambulating the client?
Correct Answer: A
Rationale: The client should be assisted to a sitting position prior to standing. This action can prevent orthostatic hypotension. Marching in place and raising the client's arms above his head are not necessary prior to ambulation. While knowing about the client's last fall can be important, it is not the priority action before ambulating the client.
Question 2 of 5
The nurse is teaching the client, who is 24 hours post abdominal surgery, how to use an IS. Which instructions should the nurse include in the teaching? Select all that apply.
Correct Answer: A,B,C,E
Rationale: A: Deep inhalation maximizes alveolar inflation. B: Sealing prevents air leaks. C: Holding breath enhances lung expansion. E: Splinting reduces pain, aiding inhalation. D: High Fowler's position is optimal. F: Slow exhalation prevents hyperventilation.
Question 3 of 5
Which is an appropriate outcome for the nursing diagnosis of Body Image Disturbance for a client with anorexia nervosa?
Correct Answer: C
Rationale: Part of the problem for anorexic clients is an altered view of their body appearance (visualizing themselves as fat even when they are emaciated). Knowledge of a maintenance diet involves a knowledge deficit. Assertiveness with family involves possible resolution of family-dynamic issues. Control of obsessive behaviors involves psychological adaptation.
Question 4 of 5
The nurse is observing the nursing student caring for the client with an artificial eye. What action by the student nurse would require intervention?
Correct Answer: B
Rationale: B: The prosthetic eye should be moist to facilitate insertion; drying it could cause trauma to the socket. A: Lying down aids safe removal. C: Normal saline is appropriate for cleansing. D: Periodic removal every 1-3 weeks is recommended.
Question 5 of 5
The client is in skeletal traction with 20 lb of traction applied to a right lower leg fracture. Which intervention should the nurse perform at regular intervals?
Correct Answer: A
Rationale: A: Regular pin site care prevents infection. B: Weights are only removed in emergencies. C: Repositioning disrupts alignment. D: ROM is avoided to maintain traction.