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NCLEX-PN Exam Questions - Part 11
1. To remove hard contact lenses from an unresponsive client, the nurse should:
A) gently irrigate the eye with an irrigating solution from the inner canthus outward.
B) grasp the lens with a gentle pinching motion.
C) don sterile gloves before attempting the procedure.
D) ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens.
2. To remove a client - s gown when she has an intravenous line, the nurse should:
A) temporarily disconnect the intravenous tubing at a point close to the client and thread it through the gown.
B) cut the gown with scissors.
C) thread the bag and tubing through the gown sleeve, keeping the line intact.
D) temporarily disconnect the tubing from the intravenous container and thread it through the gown.
3. When making an occupied bed, it is important for the nurse to:
A) keep the bed in the low position.
B) use a bath blanket or top sheet for warmth and privacy.
C) constantly keep side rails raised on both sides.
D) move back and forth from one side to the other when adjusting the linens.
4. Diagnostic genetic counseling, for procedures such as amniocentesis and chorionic villus sampling, allows clients to make all of the following choices except:
A) terminating the pregnancy.
B) preparing for the birth of a child with special needs.
C) accessing support services before the birth.
D) completing the grieving process before the birth.
5. A client who is experiencing infertility says to the nurse, 'I feel I will be incomplete as a man/woman if I cannot have a child.' Which of the following nursing diagnoses is likely to be appropriate for this client?
A) Risk for Self Harm
B) Body Image Disturbance
C) Ineffective Role Performance
D) Powerlessness
A) gently irrigate the eye with an irrigating solution from the inner canthus outward.
B) grasp the lens with a gentle pinching motion.
C) don sterile gloves before attempting the procedure.
D) ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens.
2. To remove a client - s gown when she has an intravenous line, the nurse should:
A) temporarily disconnect the intravenous tubing at a point close to the client and thread it through the gown.
B) cut the gown with scissors.
C) thread the bag and tubing through the gown sleeve, keeping the line intact.
D) temporarily disconnect the tubing from the intravenous container and thread it through the gown.
3. When making an occupied bed, it is important for the nurse to:
A) keep the bed in the low position.
B) use a bath blanket or top sheet for warmth and privacy.
C) constantly keep side rails raised on both sides.
D) move back and forth from one side to the other when adjusting the linens.
4. Diagnostic genetic counseling, for procedures such as amniocentesis and chorionic villus sampling, allows clients to make all of the following choices except:
A) terminating the pregnancy.
B) preparing for the birth of a child with special needs.
C) accessing support services before the birth.
D) completing the grieving process before the birth.
5. A client who is experiencing infertility says to the nurse, 'I feel I will be incomplete as a man/woman if I cannot have a child.' Which of the following nursing diagnoses is likely to be appropriate for this client?
A) Risk for Self Harm
B) Body Image Disturbance
C) Ineffective Role Performance
D) Powerlessness
1. Right Answer: D
Explanation: To remove hard contact lenses, the upper and lower eyelids are gently maneuvered to help loosen the lens and slide it out of the eye. The lens must be situated on the cornea, not the sclera, before removal. An attempt to grasp a hard lens might result in a scratch on the cornea. Clean gloves are an option if drainage is present. Basic Care and Comfort
2. Right Answer: C
Explanation: Threading the bag and tubing through the gown sleeve keeps the system intact. Opening an intravenous line causes a break in a sterile system and introduces the potential for infection. Cutting a gown off is not an alternative except in an emergency. IV gowns, which open along sleeves, are widely available. Basic Care andComfort
3. Right Answer: B
Explanation: Using a bath blanket or top sheet keeps the client warm and provides privacy. Keeping the bed in the low position and working above raised side rails might strain the nurses back. Continually moving back and forth to tuck and arrange linen is time-consuming and disorganized. Basic Care and Comfort
4. Right Answer: D
Explanation: If findings are ominous, the grieving process will not be completed before birth. If the couple elects to terminate a pregnancy based on diagnostic tests, there will be grief and concerns for future pregnancies. Couples might choose to access support services and prepare for the birth of an infant with special needs. Some fetal conditions can be treated in utero. Health Promotion and Maintenance
5. Right Answer: B
Explanation: Of the nursing diagnoses listed, the clients statement most represents Body Image Disturbance because it directly refers to loss of the function of having a child.Nothing in the statement indicates that the client is at risk for harming herself. Ineffective Role Performance could be correct but is not the best choice because the statement does not reflect a disruption of the parents role. Powerlessness could be an appropriate nursing diagnosis if the client described feeling powerless about the infertility. Health Promotion and Maintenance
Explanation: To remove hard contact lenses, the upper and lower eyelids are gently maneuvered to help loosen the lens and slide it out of the eye. The lens must be situated on the cornea, not the sclera, before removal. An attempt to grasp a hard lens might result in a scratch on the cornea. Clean gloves are an option if drainage is present. Basic Care and Comfort
2. Right Answer: C
Explanation: Threading the bag and tubing through the gown sleeve keeps the system intact. Opening an intravenous line causes a break in a sterile system and introduces the potential for infection. Cutting a gown off is not an alternative except in an emergency. IV gowns, which open along sleeves, are widely available. Basic Care andComfort
3. Right Answer: B
Explanation: Using a bath blanket or top sheet keeps the client warm and provides privacy. Keeping the bed in the low position and working above raised side rails might strain the nurses back. Continually moving back and forth to tuck and arrange linen is time-consuming and disorganized. Basic Care and Comfort
4. Right Answer: D
Explanation: If findings are ominous, the grieving process will not be completed before birth. If the couple elects to terminate a pregnancy based on diagnostic tests, there will be grief and concerns for future pregnancies. Couples might choose to access support services and prepare for the birth of an infant with special needs. Some fetal conditions can be treated in utero. Health Promotion and Maintenance
5. Right Answer: B
Explanation: Of the nursing diagnoses listed, the clients statement most represents Body Image Disturbance because it directly refers to loss of the function of having a child.Nothing in the statement indicates that the client is at risk for harming herself. Ineffective Role Performance could be correct but is not the best choice because the statement does not reflect a disruption of the parents role. Powerlessness could be an appropriate nursing diagnosis if the client described feeling powerless about the infertility. Health Promotion and Maintenance
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