NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. What is the purpose of the hydraulic lift (Hoyer lift)?
- A. To assist clients who have had orthopedic surgery.
- B. To assist clients who are unable to stand and extremely obese clients.
- C. To assist clients of all ages in a hospital setting.
- D. To assist clients with special needs.
Correct answer: B
Rationale: The purpose of the hydraulic lift, also known as the Hoyer lift, is to facilitate safe transfers for clients who cannot stand or are extremely obese. It is specifically designed for assisting clients who are unable to stand and for those who are too heavy for healthcare workers to lift safely. Choice A is incorrect because the primary purpose of a hydraulic lift is not related to orthopedic surgery. Choice C is incorrect because it is too broad and does not capture the specific use of the hydraulic lift. Choice D is incorrect because the lift is not solely for clients with special needs but rather for those who cannot stand or are extremely obese.
2. While caring for the following clients, a pediatric nurse tells the charge nurse she must leave due to a family emergency. Which client would the charge nurse reassign to an LPN?
- A. An eight-year-old in diabetic ketoacidosis
- B. A six-year-old in sickle cell crisis
- C. A two-month-old with dehydration
- D. A five-year-old in skeletal traction
Correct answer: D
Rationale: The correct answer is a five-year-old in skeletal traction. This task is within the scope of practice for an LPN and would need minimal assistance from an RN. The children with diabetic ketoacidosis, sickle cell crisis, and dehydration require close observation, good assessment skills, IVF needs, and medications that would be better managed by an RN. Reassigning the child in skeletal traction to an LPN ensures appropriate care while allowing the RN to focus on the more critical cases.
3. What can happen if a restraint is attached to a side rail or other movable part of the bed?
- A. Do nothing to the client.
- B. Injure the client if the rail or bed is moved.
- C. Help the client stay in the bed without falling out.
- D. Help the client with better posture.
Correct answer: B
Rationale: Attaching a restraint to a movable part of the bed can lead to client injury if that part of the bed is moved before releasing restraints. This could result in the client getting caught or trapped, possibly causing harm. Choices C and D are incorrect because attaching restraints to movable parts of the bed is not intended to help the client stay in bed or improve posture; rather, it poses a risk of injury. Choice A is incorrect as it does not address the potential harm associated with using restraints on movable parts of the bed.
4. 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.
5. Why is accurate documentation of assessment findings regarding pressure ulcers crucial?
- A. To comply with legal requirements for documenting lesions.
- B. To meet hospital policies for documenting lesions.
- C. To fulfill physician's documentation requirements for lesions.
- D. Because the nursing assessment of ulcers is a standard of nursing practice.
Correct answer: D
Rationale: Accurate documentation of assessment findings regarding pressure ulcers is crucial because the nursing assessment of ulcers is a standard practice in nursing care. Documenting these findings not only ensures continuity of care but also plays a vital role in preventing further progression of the ulcer. Choices A, B, and C are incorrect because while laws, hospital policies, and physician requirements may influence documentation practices, the primary reason for accurate documentation lies in the standards of nursing practice and the quality of patient care.
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