NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. After administering medication through an NG tube, the client asks if he can lie down when the nurse leaves the room. What is the most appropriate response?
- A. You can lie down in 1 hour.
- B. You can lie down in 5 minutes if your NG residual is below 50 mLs.
- C. You can lie down in about 30 minutes.
- D. Yes, feel free to lie down.
Correct answer: C
Rationale: The correct answer is to inform the client that they can lie down in about 30 minutes. After administering medication through an NG tube, it is recommended that the client remains upright for about 30 minutes to ensure proper absorption of the medications. Option A is incorrect as waiting for 1 hour is unnecessary. Option B is incorrect as the specified timeframe and condition given are not standard practice for lying down after NG tube medication administration. Option D is incorrect as it lacks guidance on the appropriate waiting time and does not emphasize the importance of waiting before lying down for optimal medication absorption.
2. All of the following interventions should be performed when fetal heart monitoring indicates fetal distress except:
- A. increase maternal fluids
- B. administer oxygen
- C. decrease maternal fluids
- D. turn the mother
Correct answer: C
Rationale: When fetal distress is indicated, interventions are aimed at improving oxygenation and blood flow to the fetus. Increasing maternal fluids helps improve blood flow and oxygen delivery, administering oxygen increases oxygenation levels, and turning the mother can help optimize fetal oxygenation. Decreasing maternal fluids would negatively impact blood volume and can worsen fetal distress, making it the exception among the listed interventions. Therefore, decreasing maternal fluids should not be performed when fetal distress is present.
3. The LPN is caring for a 32-year-old female client who is 8 hours post-op after a tonsillectomy. Which of these actions would be appropriate for the nurse to take?
- A. Inform the client that ear pain may occur and is normal.
- B. Provide ice water and a straw to promote easy fluid consumption.
- C. Provide hot tea to soothe the throat.
- D. Monitor vitals every 15 minutes.
Correct answer: A
Rationale: The appropriate action for the nurse to take is to inform the client that ear pain may occur and is normal after a tonsillectomy. Referred pain in the ear is common due to related nerve pathways. It is essential to educate the client about this to alleviate concerns. Providing ice water and a straw is not recommended as they may irritate the throat and disturb the healing process. Hot beverages like tea should also be avoided for the same reason. While monitoring vitals every 15 minutes is crucial in the immediate postoperative period for early identification of any complications, it is not the most appropriate action in this scenario where addressing the client's concerns and providing education is key.
4. What is the purpose of the hydraulic lift (Hoyer lift)?
- A. To assist clients who have had orthopedic surgery.
- B. To assist clients who are unable to stand and extremely obese clients.
- C. To assist clients of all ages in a hospital setting.
- D. To assist clients with special needs.
Correct answer: B
Rationale: The purpose of the hydraulic lift, also known as the Hoyer lift, is to facilitate safe transfers for clients who cannot stand or are extremely obese. It is specifically designed for assisting clients who are unable to stand and for those who are too heavy for healthcare workers to lift safely. Choice A is incorrect because the primary purpose of a hydraulic lift is not related to orthopedic surgery. Choice C is incorrect because it is too broad and does not capture the specific use of the hydraulic lift. Choice D is incorrect because the lift is not solely for clients with special needs but rather for those who cannot stand or are extremely obese.
5. Which of these types of fluid output is not typically measured?
- A. chest tube drainage
- B. emesis
- C. evaporative water from the respiratory tract
- D. urine
Correct answer: D
Rationale: The correct answer is 'urine.' Urine output is routinely measured to assess renal function and fluid balance. Choices A, B, and C are types of fluid output that are typically measured in a clinical setting. Chest tube drainage is monitored to evaluate drainage from the chest cavity, emesis refers to vomitus which can indicate gastrointestinal issues, and evaporative water from the respiratory tract is considered insensible loss and is not directly measured but estimated in overall fluid balance assessments.
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