NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. What does carrying a donor card for organ donation mean?
- A. medical care is altered to obtain organs for donation in the event of serious injuries
- B. the family or legally responsible party of a client has no decision-making authority in the event that the client is considered for organ donation
- C. a client is allowed to revoke their decision for organ donation at any time
- D. a client is considered an organ donor for multiple organs or tissues
Correct answer: C
Rationale: Carrying a donor card for organ donation signifies that an individual can decide to revoke their decision for organ donation at any point. This choice empowers the individual to change their mind regarding organ donation. The family or legally responsible party of a client still holds decision-making authority in the event that the client is considered for organ donation. When organ donation is being considered, all organs or tissues the donor wishes to donate are evaluated for donation suitability; it's not limited to just one organ or tissue. It's important to note that medical care for an individual is not altered to hasten the declaration of death for organ donation purposes; the focus is on providing immediate care and resuscitation to the individual.
2. While repositioning a comatose client, the nurse senses a tingling sensation as she lowers the bed. What action should she take?
- A. Unplug the bed's power source.
- B. Remove the client from the bed immediately.
- C. Notify the biomedical department at once.
- D. Turn off the oxygen.
Correct answer: A
Rationale: The correct action for the nurse to take when sensing a tingling sensation while lowering the bed with a comatose client is to unplug the bed's power source. This should be the initial step as there may be a fault in the bed's grounding. Removing the client from the bed immediately is not safe until the electrical issue is resolved. Notifying the biomedical department is important but should come after ensuring the immediate safety of the client. Turning off the oxygen is not necessary unless there is a specific issue related to oxygen delivery, which is not indicated in this scenario.
3. The LPN notices a client with poor gait and balance. She is currently being treated for hypertension, but the nurse is concerned. What should the nurse do?
- A. Add this issue to the nursing care plan and include daily gait/balance training as an intervention.
- B. Do nothing as this is unrelated to the client's hospitalization.
- C. Speak with the attending physician about the concerns and request a referral for the client to go to physical therapy.
- D. Speak with the attending physician about the concerns and request a referral to physical therapy.
Correct answer: D
Rationale: Nurses should address any concerns regarding a client's health, even if they are not directly related to the reason for hospitalization. In this case, the nurse noticing the client's poor gait and balance should communicate these concerns to the attending physician. The correct course of action is to request a referral to physical therapy, as this specialized intervention can help address the client's issues effectively. Adding gait/balance training to the care plan without professional assessment and intervention may not be appropriate. Doing nothing is not in line with providing comprehensive care, and referring the client to the hospital gym is not as effective as a referral to physical therapy for addressing gait and balance issues.
4. A licensed practical nurse (LPN) in the long-term care unit who has another LPN and a nursing assistant on the nursing team is planning task assignments for the day. Which task should the nurse assign to the LPN?
- A. Monitoring a client receiving oxygen who requires frequent pulse oximetry monitoring and respiratory treatments
- B. Assisting a client who is wearing eye patches and requires assistance with hygiene measures
- C. Feeding a client on bedrest who needs assistance with feeding
- D. Turning a client who must be turned and repositioned every 2 hours
Correct answer: A
Rationale: When a nurse assigns tasks for a client's care to another staff member, the nurse is responsible for appropriately assigning tasks based on the educational level and competency of the staff member. In this scenario, the LPN should be assigned the task of monitoring a client receiving oxygen who requires frequent pulse oximetry monitoring and respiratory treatments. This is because the LPN is competent to perform these tasks and can accurately note changes in the client's condition. Tasks such as feeding a client, turning and repositioning a client, and assisting with hygiene measures, which are noninvasive interventions, can be assigned to a nursing assistant. These tasks do not require the same level of assessment and monitoring as the respiratory treatments and pulse oximetry monitoring.
5. The nurse is teaching a client about erythema infectiosum. Which of the following factors is not correct?
- A. There is no rash.
- B. The disorder is uncommon in adults.
- C. There is no fever.
- D. There is sometimes a 'slapped face' appearance.
Correct answer: B
Rationale: The correct answer is B: 'The disorder is uncommon in adults.' Erythema infectiosum, also known as Fifth's disease, is more common in children than in adults. It typically presents with a rash on the face that gives a 'slapped cheek' or 'slapped face' appearance. Fever may be present, and there is a characteristic rash associated with the condition. Therefore, the statement 'The disorder is uncommon in adults' is incorrect, making it the correct answer. The other statements are true regarding erythema infectiosum, making them incorrect choices. There is indeed a rash associated with erythema infectiosum, which can be a prominent feature. Fever may also be present in individuals with this condition. Additionally, the 'slapped face' appearance is a classic characteristic of erythema infectiosum.
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