NCLEX PN 2021 PDF-collection of best Actual Exam-Modified

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NCLEX PN 2021 PDF-collection of best Actual Exam-Modified oom. Place the following steps in ascending chrono￾logical order as to how protective wear should be re￾moved. Use all the options. Answ... er: Rationale: Removal of gloves, then mask, gown, and eyewear, and then washing hands for a minimum of 10 seconds limits the possibility of contact with conta￾minants. Nursing process step: Implementation Client needs category: Safe, effective care environ￾ment Client needs subcategory: Safety and infection con￾trol Cognitive level: Comprehension BASIC PHYSICAL CARE 3 4. A client is ordered to receive a sodium phosphate enema for relief of constipation. Proper administration of the enema includes which steps? Select all that apply.
1. Chill the solution by placing it in the refrigerator for 10 minutes.
2. Assist the client into Sims’ position.
3. Wash hands and put on gloves.
4. Insert the tip of the container 1 ⁄2 into the rec￾tum.
5. Allow gravity to instill the solution.
6. Encourage the client to retain the solution for 5 to 15 minutes. Answer: 2, 3, 6 Rationale: To administer an enema, the nurse should place the client in Sims’ position or a knee-chest posi￾tion. Washing hands and putting on gloves are neces￾sary to reduce the transmission of microorganisms. To promote the effectiveness of the enema, the nurse should encourage the client to retain the solution for at least 5 minutes. The solution should be warmed rather than chilled to promote comfort. To administer the solution effectively and deliver it to the appropriate location, the nurse should insert the full length of the tip into the rectum. The nurse should compress the container to deliver the solution under positive pres￾sure and not by gravity. Nursing process step: Implementation Client needs category: Physiological integrity Client needs subcategory: Basic care and comfort Cognitive level: Application 1. Remove eyewear. 2. Remove gloves. 4. Remove gown. 3. Remove mask. 5. Wash hands for a minimum of 10 seconds. 2. Remove gloves. 3. Remove mask. 1. Remove eyewear. 4. Remove gown. 5. Wash hands for a minimum [Show More]

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