NCLEX-PN Test #12 2 — Questions and Answers
Question 1: A client is admitted with methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which precautions are required?
- Airborne precautions with N95 respirator
- Contact precautions with gown and gloves for all room entries (Correct answer)
- Droplet precautions with surgical mask
- Standard precautions only — MRSA is not transmissible
Correct answer: Contact precautions with gown and gloves for all room entries
MRSA is transmitted by direct contact with colonized or infected wounds, skin, or environmental surfaces. Contact precautions require: gown and gloves upon room entry, dedicated or clean equipment, hand hygiene with soap and water or alcohol rub, and private room when possible. MRSA is NOT transmitted by air or large droplets.
Question 2: The PN is caring for a client who will undergo surgery under general anesthesia. Which preoperative finding requires the nurse to notify the anesthesiologist?
- Client takes a daily multivitamin
- Client has a blood pressure of 132/82 mmHg
- Client reports a loose front tooth (Correct answer)
- Client last ate 10 hours ago
Correct answer: Client reports a loose front tooth
A loose tooth is a significant finding for the anesthesiologist because laryngoscopy for intubation can dislodge a loose tooth, causing it to be aspirated into the airway (aspiration, airway obstruction). The anesthesiologist must be made aware to plan intubation technique accordingly or arrange dental consultation.
Question 3: The PN is performing a sterile dressing change. Which action would break sterile technique?
- Opening sterile packages by the outer wrapper without touching the inner contents
- Placing sterile items at the center of the sterile field
- Reaching over the sterile field to place a sterile item on the far side (Correct answer)
- Pouring sterile solution while holding the bottle above the container without touching it
Correct answer: Reaching over the sterile field to place a sterile item on the far side
Reaching over a sterile field contaminates it because unsterile clothing or hands pass over the field, allowing particles to fall onto the sterile area. Items must always be placed at the edges of the field without crossing over it, or by approaching from the side. A sterile field is considered contaminated if it is below waist level, wet, or if there is a question of sterility.
Question 4: The nurse receives a client from the OR after a laparoscopic cholecystectomy. The client reports right shoulder pain. The nurse recognizes this as:
- A sign of internal bleeding requiring immediate action
- Referred pain from residual CO₂ gas in the abdomen irritating the diaphragm — expected finding (Correct answer)
- Wound dehiscence at the port site
- Liver laceration complication
Correct answer: Referred pain from residual CO₂ gas in the abdomen irritating the diaphragm — expected finding
Right shoulder pain after laparoscopic surgery is referred pain (phrenic nerve irritation) caused by residual carbon dioxide gas under the diaphragm. CO₂ is used to insufflate the abdomen during the procedure. The pain typically resolves within 24–48 hours as the gas is absorbed. Positioning and ambulation help relieve discomfort.
Question 5: A client is being discharged after abdominal surgery. Which wound care instruction indicates a need for re-teaching?
- "I will keep the incision clean and dry until it fully heals."
- "I will report any new redness, warmth, or drainage with a foul odor."
- "I can remove my steri-strips by pulling them off forcefully on day 3 to speed healing." (Correct answer)
- "I should not lift anything over 10 pounds for 4–6 weeks."
Correct answer: "I can remove my steri-strips by pulling them off forcefully on day 3 to speed healing."
Steri-strips (wound closure adhesive strips) should not be forcefully removed. They are designed to fall off on their own, typically within 7–10 days as the incision heals. Premature or forceful removal can disrupt the wound edges and cause dehiscence, especially in the early healing phase.
Question 6: The nurse is assigned to care for four postoperative clients. Which client should be assessed first?
- A client 8 hours post-appendectomy with a pain rating of 5/10
- A client 2 hours post-thyroidectomy reporting neck tightness and difficulty swallowing (Correct answer)
- A client post-hip replacement asking for assistance to the bathroom
- A client post-hernia repair with nausea and requesting antiemetics
Correct answer: A client 2 hours post-thyroidectomy reporting neck tightness and difficulty swallowing
After thyroidectomy, neck tightness and difficulty swallowing are signs of hemorrhage and hematoma formation causing tracheal compression — a life-threatening airway emergency. This requires immediate assessment and intervention. Post-thyroidectomy hemorrhage and hypocalcemia (tetany) are the two most critical complications to monitor.
NCLEX-PN Test #12 2
A client is admitted with methicillin-resistant Staphylococcus aureus (MRSA) wound infection.
Which precautions are required?