NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. Which of the following statements from a client may indicate that they are at a higher risk for a fall?
- A. "I would like to get out of bed but would like to put on my non-skid socks first."?
- B. "Can you make sure the two bedrails are raised before leaving the room?"?
- C. "I think I'm ready to walk a longer distance with the cane today."?
- D. "I need to get out of bed to go to the bathroom now. I cannot find my glasses but cannot wait."?
Correct answer: D
Rationale: The correct answer is 'I need to get out of bed to go to the bathroom now. I cannot find my glasses but cannot wait.' This statement indicates that the client is in a hurry and unable to find their glasses, which could increase the risk of a fall due to impaired vision. Choice A about putting on non-skid socks shows the client's awareness of fall prevention, reducing the risk. Choice B demonstrates the client's request for bedrails to be raised, which is a safety measure, reducing the risk as well. Choice C suggests the client's readiness to walk a longer distance with a cane, indicating progress in mobility but not necessarily a higher fall risk.
2. All of the following clients are in need of an emergency assessment except:
- A. a bleeding client who has an injury from falling debris.
- B. an unresponsive client.
- C. a client with an old injury.
- D. a pregnant woman with imminent delivery.
Correct answer: C
Rationale: The correct answer is 'a client with an old injury.' Emergency assessments are required for immediate and life-threatening situations. Clients A, B, and D are in need of emergency assessments due to their critical conditions. Choice C, a client with an old injury, does not require an emergency assessment as it is not an acute or life-threatening situation. While the client with an old injury may still need medical attention, it does not necessitate an emergency assessment as the condition is not currently life-threatening or in need of immediate intervention.
3. How is the information documented on incident reports used?
- A. to analyze risk categories
- B. to ensure compliance with regulations
- C. to identify staff's educational needs
- D. all of the above
Correct answer: D
Rationale: The information documented on incident reports is used for various purposes, including analyzing risk categories, ensuring compliance with regulations, and identifying staff's educational needs. Incident reports provide valuable data that can be utilized in risk management, quality monitoring, and improvement programs. Therefore, the correct answer is 'all of the above.' Choices A, B, and C are all correct as incident reports are used for analyzing risk categories, ensuring compliance with regulations, and identifying staff's educational needs, respectively. Thus, the most comprehensive answer is 'all of the above.'
4. Upon first meeting, a new nurse manager makes eye contact, smiles, initiates conversation about the previous work experience of nurses, and encourages active participation by nurses in the dialogue. Her behavior is an example of:
- A. Aggressiveness.
- B. Passive aggressiveness.
- C. Passiveness.
- D. Assertiveness.
Correct answer: D
Rationale: The correct answer is 'Assertiveness.' This nurse manager is demonstrating assertive behavior by confidently engaging with the nurses, showing interest in their work experience, and encouraging active participation. Aggressive behavior is forceful and dominating, while passive behavior is submissive and timid. Passive-aggressive behavior involves indirect manipulation or control, which is not demonstrated in this scenario.
5. When ambulating a client with right-sided weakness, a nursing assistant should be positioned on which side of the client?
- A. Stands behind the client
- B. Positions the free hand on the client's shoulder
- C. Stands on the right side of the client
- D. Grasps the security belt in the midspine area of the small of the client's back
Correct answer: C
Rationale: When ambulating a client with right-sided weakness, the nursing assistant should stand on the affected side, which in this case is the client's right side. This position allows the assistant to provide proper support and assistance. Standing behind the client (Choice A) is incorrect as the assistant should be on the affected side. Positioning the free hand on the client's shoulder (Choice B) is a correct action as it helps in pulling the client toward them in case of a forward fall. Grasping the security belt in the midspine area of the small of the client's back (Choice D) is also correct to provide support and stability during ambulation.
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