NCLEX-PN Procedures Practice Questions (110 Flashcards)

Hold the cane on the strong side (Right). Sequence: Move the cane forward 6-10 inches, then the weak (Left) leg, then the strong (Right) leg past the cane. Rationale: The cane on the strong side provides a wider base of support and reduces weight on the affected limb. Mnemonic: COAL (Cane Opposite Affected Leg). Cane height should be at the greater trochanter with 15-30 degrees of elbow flexion. Exam Strategy: NCSBN often tests the strong side rule; remember the cane and weak leg move together or the cane moves just before the weak leg to provide support.

The nurse should first stop the flow of the irrigation fluid (clamp the tubing) and allow the client to rest. Cramping is often caused by fluid that is too cold, infusing too rapidly, or the irrigation bag being hung too high. Once the cramping subsides, the nurse can resume the infusion at a slower rate. Bag height should be 12-18 inches (30-45 cm) above the stoma.

Suspect Fluid Volume Overload (Hypervolemia). Priority: Slow the IV rate to a Keep Vein Open (KVO) rate (usually 10-20 mL/hr) or stop it, elevate the head of the bed (High-Fowler's), and notify the RN/Provider. Rationale: Elderly clients have decreased cardiac/renal reserve and are high risk for pulmonary edema. NCLEX Tip: In PN questions, prioritize physical positioning (airway/breathing) and reducing the cause (slowing the rate) before calling the provider.

Sterile technique is required in the hospital setting. Use sterile normal saline to rinse and clean the cannula. If using a brush to remove crusting, the brush must be sterile. Clinical Reasoning: The inner cannula is part of the lower airway; introduction of bacteria can lead to ventilator-associated pneumonia (VAP) or tracheobronchitis. LPNs must maintain strict surgical asepsis during this task.

Cleanse the wound with sterile normal saline to remove old exudate and skin flora. Rationale: Culturing old drainage or skin surface bacteria leads to inaccurate results. The culture should reflect the pathogens within the wound bed tissue. NCLEX Tip: Swab the healthiest-looking granulation tissue using a rotating motion, applying enough pressure to elicit tissue fluid. Avoid touching the wound edges.