NCLEX-PN Test #3 1

Question 1

A nurse is caring for a client with a stage 3 pressure injury on the sacrum. The wound has yellow slough and minimal drainage. Which type of dressing is most appropriate?

Accepted Answer

Moist wound environment dressing such as a hydrocolloid

Answer

Dry gauze dressing changed every 8 hours

Answer

Wet-to-dry saline dressing

Answer

Transparent film dressing

Question 2

A postoperative client has a surgical incision that appears red, warm, and swollen with purulent drainage on day 3. The client's temperature is 38.9°C (102°F). The nurse should first:

Accepted Answer

Obtain a wound culture before initiating wound care

Answer

Reinforce the dressing with sterile gauze

Answer

Apply a warm compress to the incision

Answer

Irrigate the wound with hydrogen peroxide

Question 3

A nurse is performing a sterile dressing change. During the procedure, the nurse's sterile glove touches the side rail of the bed. Which action should the nurse take?

Accepted Answer

Stop, discard the contaminated gloves, and re-glove

Answer

Continue the procedure and document the contamination

Answer

Wipe the glove with an alcohol swab and continue

Answer

Proceed carefully, keeping the contaminated hand away from the wound

Question 4

A client with MRSA is on contact precautions. A nursing assistant is about to enter the room to deliver a meal tray. Which PPE should the nursing assistant wear?

Accepted Answer

Gloves and gown

Answer

Surgical mask and eye protection only

Answer

N95 respirator and gloves

Answer

No PPE is required for meal delivery only

Question 5

A nurse is caring for an older adult client who has a urinary catheter in place for 5 days. The client is now febrile and confused with foul-smelling urine. The nurse should first:

Accepted Answer

Obtain a urine culture and notify the provider

Answer

Increase oral fluid intake to flush the catheter

Answer

Change the urinary catheter immediately without an order

Answer

Administer acetaminophen for fever and recheck in 4 hours

Question 6

A nurse notes that a client's central venous catheter insertion site has redness, induration, and warmth. The client denies pain. What is the nurse's priority action?

Accepted Answer

Notify the provider and prepare for possible catheter removal

Answer

Apply a warm compress and continue monitoring every shift

Answer

Document as a normal finding post-insertion

Answer

Flush the catheter with heparin and observe for 24 hours