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

A moist wound environment promotes healing and autolytic debridement. Hydrocolloid dressings are appropriate for stage 3 wounds with slough because they maintain moisture and facilitate debridement. Wet-to-dry dressings are outdated and cause trauma. Transparent films are for stage 1 or superficial wounds.

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

Signs and symptoms indicate a wound infection. A wound culture should be obtained before starting wound care or antibiotics to identify the causative organism and guide treatment. Hydrogen peroxide is cytotoxic to healing tissue and should not be used. Warm compresses are not appropriate for infected surgical wounds.

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

When a sterile glove contacts a non-sterile surface, it is considered contaminated. The nurse must stop, remove and discard the contaminated gloves, and apply a new pair of sterile gloves. Continuing with a contaminated glove risks introducing infection into 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

Contact precautions require gloves and gown upon entering the room, regardless of the nature of the task. MRSA is spread by direct and indirect contact. An N95 is required for airborne precautions (e.g., TB, measles), not contact precautions.

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

The client's symptoms are consistent with a catheter-associated urinary tract infection (CAUTI). The priority is to obtain a urine culture (which will guide antibiotic therapy) and notify the provider. Culture should be obtained before antibiotics are given. Changing the catheter without an order exceeds the PN scope.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #3 1