NCLEX-PN Test #7 3 — Questions and Answers
Question 1: A client with a stage III pressure injury has yellow slough in the wound bed. Which wound care intervention is indicated?
- Pack the wound tightly with dry gauze
- Apply a moisture-retentive dressing and consult wound care as debridement is needed (Correct answer)
- Irrigate with full-strength hydrogen peroxide daily
- Apply an antimicrobial ointment and leave the wound open to air
Correct answer: Apply a moisture-retentive dressing and consult wound care as debridement is needed
Yellow slough in a wound bed indicates the presence of non-viable fibrinous tissue that must be debrided for wound healing to progress. Moist wound healing (moisture-retentive dressings) and debridement are evidence-based interventions. Hydrogen peroxide and drying the wound delay healing and damage new granulation tissue.
Question 2: The PN is preparing a client for a scheduled abdominal surgery. Which preoperative assessment finding requires the nurse to notify the surgeon before proceeding?
- Client reports using a continuous CPAP machine at home
- Client has not had anything by mouth for 8 hours
- Client reports taking aspirin 325 mg daily and took it this morning (Correct answer)
- Client's last bowel movement was 2 days ago
Correct answer: Client reports taking aspirin 325 mg daily and took it this morning
Aspirin is an antiplatelet drug that increases intraoperative and postoperative bleeding risk. Clients are typically instructed to stop aspirin 7–10 days before elective surgery. Taking aspirin the morning of surgery requires surgeon notification and may necessitate rescheduling or special surgical precautions.
Question 3: A client returns from surgery and has a urinary catheter in place. Which nursing intervention best prevents catheter-associated urinary tract infection (CAUTI)?
- Irrigate the catheter with antiseptic solution twice daily
- Maintain a closed drainage system and keep the bag below bladder level (Correct answer)
- Change the catheter every 72 hours as a matter of routine
- Apply antibiotic ointment to the meatus daily
Correct answer: Maintain a closed drainage system and keep the bag below bladder level
The cornerstone of CAUTI prevention is maintaining a closed drainage system (no disconnecting), keeping the drainage bag below bladder level to prevent backflow, and daily hygiene of the urethral meatus with soap and water. Routine irrigation and routine catheter changes are not evidence-based and can introduce pathogens.
Question 4: A client in the post-anesthesia care unit (PACU) has a respiratory rate of 8 breaths per minute and is difficult to arouse after receiving IV fentanyl for pain management. What is the priority intervention?
- Reposition the client to the lateral position
- Administer naloxone (Narcan) as ordered (Correct answer)
- Increase IV fluid rate to flush the opioid
- Apply a non-rebreather mask at 15 L/min
Correct answer: Administer naloxone (Narcan) as ordered
Respiratory depression (rate < 12/min) with decreased level of consciousness after opioid administration indicates opioid overdose. Naloxone (Narcan) is the opioid antagonist that reverses respiratory depression. It must be administered promptly while monitoring for re-narcotization and maintaining airway.
Question 5: The PN is assessing a surgical incision on postoperative day 3. Which finding is a normal part of wound healing?
- Thick, green exudate at the wound edges
- Wound edges separating (dehiscence)
- Pinkish-red granulation tissue in the wound bed (Correct answer)
- Persistent edema with foul odor
Correct answer: Pinkish-red granulation tissue in the wound bed
Pink-red granulation tissue is a hallmark of the proliferative phase of wound healing (days 3–21). It consists of new capillaries and collagen and is a sign of healthy wound healing. Green exudate and foul odor indicate infection; dehiscence is a wound complication, not normal healing.
Question 6: A client is at risk for deep vein thrombosis (DVT) after a total knee replacement. Which nursing intervention is most effective for prevention?
- Apply heat packs to the lower extremities
- Encourage early ambulation and use of sequential compression devices (SCDs) (Correct answer)
- Keep the client on strict bed rest for 24 hours
- Administer aspirin 325 mg twice daily for anticoagulation
Correct answer: Encourage early ambulation and use of sequential compression devices (SCDs)
Early ambulation and SCDs are the most effective non-pharmacological DVT prevention strategies after orthopedic surgery. SCDs provide intermittent mechanical compression that prevents venous stasis. Most orthopedic clients also receive pharmacological prophylaxis (LMWH or rivaroxaban). Bed rest is a major DVT risk factor.
NCLEX-PN Test #7 3
A client with a stage III pressure injury has yellow slough in the wound bed.
Which wound care intervention is indicated?