the lpn is preparing to clean a clients peg tube which of the following tasks should the nurse perform a gently remove crusty drainage from the site
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Nursing Elites

NCLEX-PN

Safe and Effective Care Environment Nclex PN Questions

1. The LPN is preparing to clean a client's PEG tube.The following tasks should the nurse perform EXCEPT?

Correct answer: B

Rationale: When cleaning a client's PEG tube, the nurse should perform tasks that focus on gentle cleaning and avoiding potential irritants. Choice A is correct as gently removing crusty drainage helps maintain hygiene. Choice C is important to prevent skin irritation and infection. Choice D is appropriate for cleaning the area. Choices B and D are incorrect. Choice B is incorrect because pulling the tube in multiple directions can lead to dislodgement or injury. Choice B is incorrect as talcum powder may irritate the stoma, and it is generally not recommended near PEG tubes.

2. A nurse enters a client's room to administer a medication that has been prescribed by the health care provider. The client asks the nurse about the medication. Which response by the nurse is appropriate?

Correct answer: B

Rationale: A client has the right to be informed of the medication name, purpose, action, and potential undesirable effects of a prescribed medication. The nurse should provide adequate information to the client. Choice B is the correct answer as it includes the medication name, its purpose (promoting urination and eliminating excess fluid), and a potential side effect (alteration in electrolyte levels) with a plan for managing it (increasing potassium in the diet). This response demonstrates thorough and complete information. Choice A provides some information but lacks details on potential side effects and dietary adjustments. Choice C is vague and does not provide specific details about the medication. Choice D deflects the client's question and does not fulfill the client's right to information.

3. A discharge planning nurse is making arrangements for a client with an epidural catheter for continuous infusion of opioids to be placed in a long-term care facility. The family prefers a facility in its neighborhood to facilitate visiting. The neighborhood facility has never cared for a client with this type of need. What is the most appropriate action by the discharge planning nurse?

Correct answer: B

Rationale: In this scenario, the priority is the safety and well-being of the client. The neighborhood facility's lack of experience in caring for a client with an epidural catheter for continuous opioid infusion raises concerns about the quality of care they can provide. Therefore, the most appropriate action for the discharge planning nurse is to explain the situation to the client and family and seek another long-term care facility that can provide the necessary care. Option A, arranging for immediate in-services, may not be feasible or timely, considering the urgent need for appropriate care. Option C, encouraging the family to hire private duty nurses, does not ensure the facility's overall capability to manage the client's complex needs. Option D, 'None of the above,' is not the best choice as the client's safety should be the priority in this situation.

4. Several passengers aboard an airliner suddenly become weak and suffer breathing difficulty. The diagnosis is likely to be:

Correct answer: B

Rationale: The most likely cause of groups of individuals suddenly experiencing similar signs of illness all at once is a chemical exposure. In this scenario, considering the sudden onset of symptoms in multiple passengers on an airliner, the symptoms are more indicative of a chemical exposure rather than Asian flu, bacterial pneumonia, or an allergic reaction. Asian flu, bacterial pneumonia, and allergic reactions do not typically manifest in a way that would affect a group of individuals simultaneously. Therefore, the correct diagnosis in this case is likely to be a chemical exposure.

5. While preparing a client for a bronchoscopy, a nurse notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client's necklace?

Correct answer: A

Rationale: When a client has valuables such as jewelry, the nurse should ensure their safekeeping. It is appropriate for the nurse to ask the client for permission to lock the necklace in the hospital safe to prevent loss or damage. This option prioritizes the security of the necklace while allowing the client to make an informed decision. Asking the client to sign a release form does not guarantee the necklace's safety; it only releases the hospital from liability. Placing the necklace in a bedside table drawer does not provide adequate security as it is not as secure as a hospital safe. Inquiring whether the necklace is gold is irrelevant to safeguarding the jewelry during the procedure, as the primary concern is its safekeeping.

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