NCLEX-PN Test #7 3

Question 1

A client with a stage III pressure injury has yellow slough in the wound bed. Which wound care intervention is indicated?

Accepted Answer

Apply a moisture-retentive dressing and consult wound care as debridement is needed

Answer

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?

Accepted Answer

Client reports taking aspirin 325 mg daily and took it this morning

Answer

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)?

Accepted Answer

Maintain a closed drainage system and keep the bag below bladder level

Answer

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?

Accepted Answer

Administer naloxone (Narcan) as ordered

Answer

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?

Accepted Answer

Pinkish-red granulation tissue in the wound bed

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

NCLEX-PN Test #7 3