Welcome to NCLEX Review - Fundamentals of Nursing Study Guide. Before you begin answering the questions, you may first want to take a peek about the material that will surely help you the pass the NCLEX examination :
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51. A registered nurse (RN) is providing postmortem care for a deceased client whose eyes will be donated. Which nursing action is required to provide sound care of the client's body?
a) close the eyes and places the bed flat
b) maintains the client in a supine position
c) irrigates the client's eyes with normal saline
d) places wet saline gauze pads on the eyelids and a small ice pack on the gauze pads
52. A nurse is caring for a client receiving parenteral nutrition (PN). Which does the nurse implement to decrease the risk of infection?
a) assesses vital signs at 4-hour intervals
b) administers prophylactic antimicrobial agents
c) checks the solution's label against the prescription
d) uses aseptic technique in handling the PH solution
53. The home care nurse provides medication instructions to a male client. To ensure that the client self-administers his medications safely in the home, the nurse:
a) performs a pill count of each prescription bottle at every home visit
b) instructs the client to double up on a medication when a dose is missed
c) demonstrates the proper procedure for self-administration of medications
d) asks the client to explain and demonstrate self-administration procedures
54. A client asks the home care nurse to witness the client's signature in a living will with the client's attorney in attendance. Which should the nurse implement?
a) decline to witness the signature on the wall
b) sign the will as a witness to the signature only
c) notify the supervisor that a living will is being witnessed
d) sign the will with identifying credentials and employment agency
55. The nurse notes old and new ecchymotic areas on an older client's arms and buttocks upon admission. The client tells the nurse in confidence that her daughter frequently hits her. Which statement should the nurse use in response?
a) I have a legal obligation to report this type of abuse
b) let's get these treated and I will maintain the confidence
c) if this happens again, you must call the emergency department
d) let's talk about ways to prevent your daughter from hitting you
Fundamentals of Nursing Study Guide
Answers and Rationale
51) D
- When a corneal donor dies, the eyes are closed and sterile gauze pads wet with saline are placed over them with a small ice pack. Within 2 to 4 hours the eyes are enucleated, and the corneas are usually transplanted within 24 to 48 hours. The head of the bed should be elevated. With the head of the bed elevated, the eyes will likely remain closed. Eye irrigations, if indicated, would be prescribed by the transplant surgeon.52) D
- Clients receiving PN are at high risk for developing infection because the concentrated glucose solutions are an excellent medium for bacterial growth. The nurse reduces the client's risk of infection by using aseptic technique when handling all equipment and solutions related to the PN infusion. Option A is a reasonable intervention for early detection of infection but does not prevent infection. Prophylactic antibiotics are not indicated for PN infusions and can contribute to the development of secondary infections. The nurse implements option C to ensure that the client receives the correct infusion.53) D
- To ensure safe administration of medication, the nurse asks the client to explain and demonstrate correct self-administration of medication procedures because demonstrating the proper procedure for the client does not ensure that the client can safely perform any procedure. Usually, it is not acceptable to double up on missed medication, and conducting a pill count on each visit is unrealistic and disrespectful.54) A
- Living wills must be written documents and signed by the client. The client's signature either must be witnessed by nonagency individuals or notarized, thus the nurse should decline to sign the will to avoid a conflict of interest. The nurse's signature on the living will testifies to the validity of the client's signature. If the nurse contacts the supervisor, the supervisor should advise the nurse to decline.55) A
- The nurse should inform the client that nurses cannot maintain confidences about alleged abusive behavior and that the nurse must report situations related to abuse. The nurse avoids bargaining with the client about treatment to maintain a confidence that the nurse is legally bound to report. Options C and D delay protective action and place the client at risk for future abuse.After you reviewed your answers through its rationale, you can also go back to the first page to start from the beginning:
NCLEX Review - Fundamentals of Nursing Study Guide (1-5)
Or proceed to the next set of questions:
NCLEX Review - Fundamentals of Nursing Study Guide (56-60)
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