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. Which action exemplifies the use of evidence-based practice in the delivery of client care?
- A. Advising a client to agree to the treatment recommended by their healthcare provider
- B. Taking a rectal temperature from a client for whom bleeding precautions have been instituted
- C. Donning sterile gloves to change an abdominal wound dressing
- D. Encouraging a client to take an herbal substance to treat their insomnia
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.
3. Which of the following is an appropriate nursing goal for a client at risk for nutritional problems?
- A. provide oxygen
- B. promote healthy nutritional practices
- C. treat complications of malnutrition
- D. increase weight
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. The goals of palliative care include all of the following except:
- A. giving clients with life-threatening illnesses the best quality of life possible.
- B. taking care of the whole person"?body, mind, spirit, heart, and soul.
- C. no interventions are needed because the client is near death.
- D. supporting the needs of the family and client.
Correct answer: C
Rationale: The correct goal of palliative care is to provide comprehensive care that addresses the physical, emotional, social, and spiritual needs of the dying client until the end of life. Therefore, the statement 'no interventions are needed because the client is near death' is incorrect as interventions are still essential to ensure comfort and quality of life. Choices A, B, and D are all aligned with the goals of palliative care, focusing on improving the quality of life, providing holistic care, and supporting both the family and the client.
5. In an obstetrical emergency, which of the following actions should the nurse perform first after the baby delivers?
- A. Place extra padding under the mother to absorb blood from the delivery.
- B. Cut the umbilical cord using sterile scissors.
- C. Suction the baby's mouth and nose.
- D. Wrap the baby in a clean blanket to preserve warmth.
Correct answer: C
Rationale: In an obstetrical emergency, the immediate action the nurse should take after the baby delivers is to suction the baby's mouth and nose to ensure the infant can breathe properly. This helps clear any potential obstructions and establish a clear airway. Cutting the umbilical cord (Choice B) and wrapping the baby in a clean blanket (Choice D) are important steps but should come after ensuring the baby's airway is clear. Placing extra padding under the mother (Choice A) is not a priority in this emergency situation as the focus should be on the baby's immediate needs for breathing and airway clearance.
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