NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. What is the correct instruction to give a client undergoing mammography?
- A. Do not use underarm deodorant.
- B. Wear comfortable clothing.
- C. Avoid caffeine prior to the procedure.
- D. Bring a list of current medications.
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.
2. When removing a client's gown with an intravenous line, what should the nurse do?
- A. temporarily disconnect the intravenous tubing at a point close to the client and thread it through the gown
- B. cut the gown with scissors
- C. thread the bag and tubing through the gown sleeve, keeping the line intact
- D. temporarily disconnect the tubing from the intravenous container and thread it through the gown
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.
3. Which of the following indicates a hazard for a client on oxygen therapy?
- A. A 'No Smoking' sign is on the door.
- B. The client is wearing a synthetic gown.
- C. Electrical equipment is grounded.
- D. Matches are removed.
Correct answer: B
Rationale: The correct answer is that the client is wearing a synthetic gown. A synthetic gown might generate sparks of static electricity, which can be a fire hazard, especially in the presence of oxygen. Clients on oxygen therapy should wear cotton gowns to minimize the risk of fire. The other options are not hazards for a client on oxygen therapy: having a 'No Smoking' sign on the door promotes safety by preventing smoking, ensuring electrical equipment is grounded reduces the risk of electrical hazards, and removing matches decreases the risk of fire hazards.
4. A 10-year-old boy has been diagnosed with a congenital heart defect. Which of the following clinical signs does not indicate CHF?
- A. Increased body weight
- B. Elevated heart rate
- C. Lower extremity edema
- D. Compulsive behavior
Correct answer: D
Rationale: Compulsive behavior is not a clinical sign typically associated with congestive heart failure (CHF). CHF commonly presents with symptoms such as increased body weight due to fluid retention, elevated heart rate as the heart works harder to pump blood effectively, and lower extremity edema caused by fluid buildup. While behavioral changes can occur in response to illness, compulsive behavior is not a typical indicator of CHF. Choices A, B, and C are more commonly linked to CHF and should be monitored in patients with this condition.
5. The nurse should teach parents of small children that the most common type of first-degree burn is:
- A. scalding from hot bath water or spills.
- B. contact with hot surfaces such as stoves and fireplaces.
- C. contact with flammable liquids or gases resulting in flash burns.
- D. sunburn from lack of protection and overexposure.
Correct answer: D
Rationale: The correct answer is 'sunburn from lack of protection and overexposure.' First-degree burns primarily affect the outer layer of the skin and are commonly caused by overexposure to the sun without adequate protection, making it a significant concern for parents of small children. Choices A, B, and C describe other types of burns (scalding, contact with hot surfaces, and contact with flammable substances) that can cause more severe burns beyond the first-degree level. It is crucial for parents to be educated about sun safety measures to prevent sunburns in children.
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