NCLEX-PN Test #12 2

Question 1

A client is admitted with methicillin-resistant Staphylococcus aureus (MRSA) wound infection. Which precautions are required?

Accepted Answer

Contact precautions with gown and gloves for all room entries

Answer

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?

Accepted Answer

Client reports a loose front tooth

Answer

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?

Accepted Answer

Reaching over the sterile field to place a sterile item on the far side

Answer

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:

Accepted Answer

Referred pain from residual CO₂ gas in the abdomen irritating the diaphragm — expected finding

Answer

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?

Accepted Answer

"I can remove my steri-strips by pulling them off forcefully on day 3 to speed healing."

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #12 2