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Planning

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NCLEX RN
Nursing Process
Planning

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Question 1 of 33

The nurse is caring for a client who is receiving total parenteral nutrition through a central venous catheter. Which action should the nurse plan to implement to decrease the risk of infection in this client?

A. Track the client's oral temperature.

B. Administer antibiotics intravenously.

C. Evaluate the differential of the leukocytes.

D. Use sterile technique for dressing changes.

Correct Answer:

Rationale:

Question 2 of 33

The nurse creates a plan of care for a client with a spica cast that covers a lower extremity. Which action should the nurse include in the plan of care to promote bowel elimination?

A. Use a bedside commode.

B. Ambulate to the bathroom.

C. Administer an enema daily.

D. Use a low-profile (fracture) bedpan.

Correct Answer:

Rationale:

Question 3 of 33

The nurse is caring for a postpartum client with thromboembolytic disease. Which intervention is most important to include when planning care to prevent the complication of pulmonary embolism?

A. Enforce bed rest.

B. Monitor the vital signs frequently.

C. Assess the breath sounds frequently.

D. Administer prescribed anticoagulant therapy.

Correct Answer:

Rationale:

Question 4 of 33

The student nurse is listening to a lecture on serum electrolyte levels and the use of isotonic solutions. Which statement by the student nurse indicates that the teaching has been effective?

A. 10% dextrose in water is a hypotonic solution.

B. 3% sodium chloride solution is a hypotonic solution.

C. 5% dextrose in water is considered an isotonic solution.

D. 0.45% sodium chloride solution is a hypertonic solution.

Correct Answer:

Rationale:

Question 5 of 33

The nurse is admitting a client who recently underwent a bilateral adrenalectomy. Which intervention is essential for the nurse to include in the client's plan of care?

A. Prevent social isolation.

B. Consider occupational therapy.

C. Discuss changes in body image.

D. Avoid stress-producing situations.

Correct Answer:

Rationale:

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