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. A nurse is watching as a new nurse employee administers an intramuscular (IM) injection in a client's deltoid muscle. The nurse determines that the new employee is performing the procedure correctly if the new employee uses which technique?
- A. Administers the injection 2 inches below the acromion process
- B. Positions the client with the deltoid muscle exposed
- C. Administers the injection in the thigh
- D. Places the client in the Sims position
Correct answer: A
Rationale: When administering an intramuscular injection in the deltoid muscle, the correct technique involves administering the injection 2 inches below the acromion process, which is the bony structure on top of the shoulder blade. This location ensures safe and effective administration. Administering the injection in the thigh (vastus lateralis or rectus femoris muscle) is not appropriate for a deltoid injection as the deltoid muscle is located in the upper arm. The Sims position is not the correct position for a deltoid muscle injection. While positioning the client with the deltoid muscle exposed allows for proper access and visualization, the critical aspect for a correct deltoid injection is the accurate injection site, 2 inches below the acromion process.
3. A nurse is reading the nurse practice act for the state in which she is employed. The nurse uses the information in this act for which purpose?
- A. To understand hospital and long-term care facility policies
- B. To know the scope of practice for nurses
- C. To identify health care policies in her state
- D. To be aware of the role of the licensed nurse
Correct answer: D
Rationale: The correct answer is 'To be aware of the role of the licensed nurse.' Nurse practice acts outline the scope of practice for nurses, defining what constitutes nursing practice and the role of licensed nurses. Choice A is incorrect because hospital and long-term care facility policies are institution-specific and not typically covered in the nurse practice act. Choice B is incorrect as the scope of practice for nurses is a part of the nurse practice act, but it's not the sole purpose for a nurse to refer to it. Choice C is incorrect as health care policies in a state are governed by other legislative acts, not the nurse practice act.
4. The nurse is educating a teenage female about preventing the transmission of genital herpes. Which of the following statements should the nurse include?
- A. "Do not sit on toilet seats without protection."?
- B. "Oral sex can transmit the virus."?
- C. "This infection can be transmitted via intercourse even when you do not feel ill."?
- D. "Try to drink plenty of fluids after sex to flush the reproductive tract."?
Correct answer: C
Rationale: Genital herpes can be transmitted through oral, genital, and anal sex. It is crucial to educate the patient that the infection can be transmitted via intercourse even when asymptomatic to prevent its spread. Choice A is incorrect as sitting on toilet seats without protection does not transmit genital herpes. Choice B is incorrect because oral sex can transmit the virus. Choice D is also incorrect as drinking fluids after sex does not prevent the transmission of genital herpes.
5. A client who has undergone a total hip replacement is told that she will need to go to an extended care rehabilitation facility for therapy before going home. Which member of the healthcare team should the nurse ask to plan the discharge and transition from the hospital to the rehabilitation facility?
- A. Physical therapist
- B. Occupational therapist
- C. Clergy
- D. Social worker
Correct answer: D
Rationale: In this scenario, the appropriate member of the healthcare team to plan the discharge and transition from the hospital to the rehabilitation facility is the social worker. Social workers are trained to provide counseling services, emotional support, arrange placements in care facilities, and locate financial resources for clients. While clergy provide spiritual support and guidance, physical therapists assist in physical treatments, and occupational therapists help with activities of daily living, the social worker is best suited to address the client's needs related to discharge planning and transition. Therefore, the correct answer is the social worker.
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