NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. When caring for clients with Buck’s Traction, the major areas of importance should be:
- A. nutrition, elimination, comfort, safety
- B. ROM exercises, transportation
- C. nutrition, elimination, comfort, safety
- D. elimination, safety, isotonic exercises
Correct answer: C
Rationale: When caring for clients with Buck’s Traction, the major areas of importance should be nutrition, elimination, comfort, and safety. Proper nutrition, including a diet high in protein with adequate fluids, is essential for healing and recovery. Elimination refers to maintaining regular bowel and bladder function. Comfort is crucial to ensure the patient's well-being while in traction, and safety measures should be followed to prevent complications. Choices A, B, and D are incorrect. ROM exercises are not typically a primary concern with Buck’s Traction, making choices A and B incorrect. Isotonic exercises are not specifically related to the care of a client in Buck's Traction, making choice D incorrect.
2. In what order should the LPN see the following clients? Use appropriate letters to match the correct order
- A. A, D, B, C
- B. C, B, D, A
- C. D, C, B, A
- D. B, C, A, D
Correct answer: B
Rationale: The correct order for the LPN to see the clients is C, B, D, A. It is crucial to prioritize client care based on the urgency of their conditions. The 53-year-old client with lower leg swelling complaining of sudden onset headache and blurry vision (Client C) should be seen first as they are at the highest risk for serious healthcare complications. Next, the LPN should attend to the 23-year-old client with a left arm fracture after an MVA complaining of significant pain in his arm (Client B). Following that, the LPN can address the 47-year-old client requesting more information regarding her surgery scheduled in three hours (Client D). Lastly, the LPN should attend to the 72-year-old client with pneumonia asking to order her dinner (Client A). This order ensures that the most critical needs are met first, followed by the less urgent ones. Choice A is incorrect as it places the 72-year-old client before the 23-year-old client with a painful arm. Choice B is incorrect as it prioritizes the 53-year-old client last. Choice D is incorrect as it does not address the urgency of the clients' conditions appropriately.
3. When making an occupied bed, what is important for the nurse to do?
- A. keep the bed in the low position.
- B. use a bath blanket or top sheet for warmth and privacy
- C. constantly keep side rails raised on both sides.
- D. move back and forth from one side to the other when adjusting the linens.
Correct answer: B
Rationale: When making an occupied bed, using a bath blanket or top sheet is important as it keeps the client warm and provides privacy, ensuring their comfort and dignity. Keeping the bed in the low position is crucial for the safety of the client, preventing falls and injuries. Constantly keeping side rails raised on both sides is unnecessary and may restrict the client's movement unnecessarily. Moving back and forth from one side to the other when adjusting the linens is inefficient and disrupts the workflow; it is more effective to work systematically from one side to the other to ensure proper bed-making.
4. How often should physical restraints be released?
- A. Every 2 hours
- B. Between 1 and 3 hours
- C. Every 30 minutes
- D. At least every 4 hours
Correct answer: A
Rationale: The correct answer is to release physical restraints every 2 hours. Releasing restraints every 2 hours helps prevent complications associated with prolonged immobilization. Releasing restraints every 30 minutes (choice C) may be too frequent and disruptive to the client's care. Releasing restraints between 1 and 3 hours (choice B) introduces variability that could lead to inconsistencies in care. Releasing restraints at least every 4 hours (choice D) does not adhere to the recommended frequency of every 2 hours.
5. The nurse is caring for a client recovering from a stroke who recently regained consciousness. The client is having difficulty communicating verbally with the team. Which of the following actions would be least appropriate?
- A. Begin client data collection before receiving the physician's order for the referral.
- B. Use documents to provide information for the referral.
- C. Wait for the physician's order for speech therapy before assisting with the appropriate documentation.
- D. Participate in the client referral process.
Correct answer: C
Rationale: In this scenario, the least appropriate action would be to wait for the physician's order for speech therapy before assisting with the appropriate documentation. The nurse should start by collecting client data without needing the physician's order, use documents to provide information for the referral, and actively participate in the client referral process. Waiting for the physician's order unnecessarily delays potentially crucial therapy for the client's recovery, affecting the timeliness and effectiveness of care. Therefore, choice C is the least appropriate as immediate action is required in such situations.
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