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. A nurse manager asks a nurse to work overtime because of a short-staffing problem. The nurse has made plans to do Christmas shopping after work and does not want to work overtime. What is the most assertive response by the nurse to her nurse manager?
- A. "I'm not working overtime today."
- B. "I have plans after work and will not be able to work overtime."
- C. "You know how I hate to work overtime."
- D. "I will if you need me, but I am not happy about this."
Correct answer: B
Rationale: The most assertive response in dealing with this conflict is the one that is direct and conveys a clear message in a positive manner. The nurse should assertively communicate her unavailability for overtime without being confrontational. Option A, "I'm not working overtime today," is too blunt and may come across as rude. Option C, "You know how I hate to work overtime," is not assertive but rather passive-aggressive. Option D, "I will if you need me, but I am not happy about this," is a passive-aggressive response as it implies compliance while expressing discontent. Option B, "I have plans after work and will not be able to work overtime," is the most appropriate response as it clearly states the nurse's unavailability without unnecessary aggression.
3. The client is being taught about the use of Rifampin for prophylaxis following exposure to meningitis. What change in bodily functions should the client be informed about?
- A. The client's urine may turn blue.
- B. The client remains infectious to others for 48 hours.
- C. The client's contact lenses may be stained orange.
- D. The client's skin may take on a crimson glow.
Correct answer: C
Rationale: Rifampin has the unusual effect of turning body fluids an orange color. Soft contact lenses might become permanently stained. Clients should be taught about these side effects to avoid unnecessary concern. Option A is incorrect as Rifampin does not cause the urine to turn blue. Option B is incorrect as the client is not infectious to others due to taking Rifampin for prophylaxis. Option D is incorrect as Rifampin does not cause the skin to take on a crimson glow.
4. A client with a pleural drainage system to suction has gentle bubbling of the water seal. What should the nurse do?
- A. Notify the physician.
- B. Clamp the chest tube.
- C. Replace the system.
- D. Document the finding
Correct answer: D
Rationale: Gentle bubbling is a normal finding for a client with a pleural drainage system to suction, so it simply needs to be documented for monitoring purposes. If the bubbling becomes vigorous, it could indicate a leak, which would then require further investigation by the nurse. Therefore, the correct action at this point is to document the finding. Notifying the physician is not necessary for gentle bubbling as it is expected. Clamping the chest tube or replacing the system is inappropriate and could potentially harm the client as there is no indication for such actions based on the scenario provided.
5. To ensure proper immobilization and increase client comfort when using a rigid splint, what should be done?
- A. Place the client on a stretcher before splinting.
- B. Place the client on a long spine board before splinting.
- C. Pad the spaces between the body part and the splint.
- D. Ensure that the splint conforms to the body curves.
Correct answer: C
Rationale: Correct. When using a rigid splint, it is essential to pad the spaces between the body part and the splint to ensure proper immobilization and increase client comfort. This padding helps prevent pressure points and ensures a proper fit of the splint without causing discomfort. Placing the client on a stretcher or a long spine board before splinting (choices A and B) may be necessary for transportation but does not directly relate to the proper use of a rigid splint. Ensuring that the splint conforms to the body curves (choice D) is important but not as crucial as padding the spaces to prevent discomfort and ensure proper immobilization.
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