to remove a clients gown when she has an intravenous line the nurse should
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Nursing Elites

NCLEX-PN

Safe and Effective Care Environment Nclex PN Questions

1. When removing a client's gown with an intravenous line, what should the nurse do?

Correct answer: C

Rationale: The correct action when removing a client's gown with an intravenous line is to thread the bag and tubing through the gown sleeve while keeping the line intact. This method ensures that the system remains sterile and reduces the risk of infection. Temporarily disconnecting the tubing at a point close to the client or from the container introduces the potential for contamination. Cutting the gown with scissors should only be done in emergencies as it is not a standard practice and can compromise the integrity of the intravenous line. Therefore, the most appropriate and safe method is to thread the bag and tubing through the gown sleeve.

2. A health care provider informs a nurse that the husband of an unconscious client with terminal cancer will not grant permission for a do-not-resuscitate (DNR) order. The health care provider tells the nurse to perform a 'slow code' and let the client 'rest in peace' if she stops breathing. How should the nurse respond?

Correct answer: D

Rationale: The nurse may not violate a family's request regarding the client's treatment plan. A 'slow code' is not acceptable, and the nurse should state this to the health care provider. The definition of a 'slow code' varies among health care facilities and personnel and could be interpreted as not performing resuscitative procedures as quickly as a competent person would. Resuscitative procedures that are performed more slowly than recommended by the American Heart Association are below the standard of care and could therefore serve as the basis for a lawsuit. The other options are inappropriate: Option A is speculative and does not address the issue directly; Option B does not challenge the unethical practice of a 'slow code'; Option C is irrelevant and does not address the ethical concerns raised by the health care provider's request.

3. Which of the following is an appropriate nursing goal for a client at risk for nutritional problems?

Correct answer: B

Rationale: The correct answer is to promote healthy nutritional practices. This goal focuses on preventive measures to address the client's nutritional risk. Providing oxygen (Choice A) is not directly related to addressing nutritional problems. Treating complications of malnutrition (Choice C) involves addressing the consequences rather than preventing or managing the nutritional problems. Increasing weight (Choice D) would only be appropriate if the client is underweight; it does not address the broader aspect of promoting overall healthy nutritional practices.

4. What is the correct instruction to give a client undergoing mammography?

Correct answer: A

Rationale: The correct instruction for a client undergoing mammography is not to use underarm deodorant. Underarm deodorant can cause confusing shadows on the X-ray film, affecting the accuracy of the mammogram. Choices B, C, and D are incorrect. While wearing comfortable clothing is advisable, it is not the primary instruction for mammography. Avoiding caffeine and bringing a list of current medications are not specific instructions related to mammography preparation and are therefore not the correct answers.

5. Which action exemplifies the use of evidence-based practice in the delivery of client care?

Correct answer: C

Rationale: Evidence-based practice is an approach to client care where the nurse integrates the client’s preferences, clinical expertise, and the best research evidence to deliver quality care. Donning sterile gloves to change an abdominal wound dressing exemplifies evidence-based practice as it prevents the entrance of harmful bacteria into the wound, following best practice guidelines. The other options do not align with evidence-based practice. Advising a client to agree to a treatment does not involve integrating research evidence. Taking herbal substances may not be supported by strong research evidence and can pose risks. Additionally, rectal temperature-taking in a client with bleeding precautions can increase the risk of injury to the rectal mucosa, not aligning with best practices in care delivery.

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