NCLEX-PN Test #3 1 — Questions and Answers
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?
- Dry gauze dressing changed every 8 hours
- Moist wound environment dressing such as a hydrocolloid (Correct answer)
- Wet-to-dry saline dressing
- Transparent film dressing
Correct answer: Moist wound environment dressing such as a hydrocolloid
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 Wet-to-dry dressings are outdated and cause trauma.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:
- Reinforce the dressing with sterile gauze
- Obtain a wound culture before initiating wound care (Correct answer)
- Apply a warm compress to the incision
- Irrigate the wound with hydrogen peroxide
Correct answer: Obtain a wound culture before initiating wound care
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?
- Continue the procedure and document the contamination
- Wipe the glove with an alcohol swab and continue
- Stop, discard the contaminated gloves, and re-glove (Correct answer)
- Proceed carefully, keeping the contaminated hand away from the wound
Correct answer: Stop, discard the contaminated gloves, and re-glove
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?
- Surgical mask and eye protection only
- Gloves and gown (Correct answer)
- N95 respirator and gloves
- No PPE is required for meal delivery only
Correct answer: Gloves and gown
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:
- Obtain a urine culture and notify the provider (Correct answer)
- Increase oral fluid intake to flush the catheter
- Change the urinary catheter immediately without an order
- Administer acetaminophen for fever and recheck in 4 hours
Correct answer: Obtain a urine culture and notify the provider
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.
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?
- Apply a warm compress and continue monitoring every shift
- Document as a normal finding post-insertion
- Notify the provider and prepare for possible catheter removal (Correct answer)
- Flush the catheter with heparin and observe for 24 hours
Correct answer: Notify the provider and prepare for possible catheter removal
Redness, induration, and warmth at a central venous catheter site are signs of local infection. The nurse must notify the provider promptly because catheter-related bloodstream infection (CRBSI) is a serious complication. The catheter may need to be removed and cultures obtained. Flushing with heparin does not treat infection.
NCLEX-PN Test #3 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?