the nurse in the emergency room is admitting a client who has sustained a gunshot wound and will require immediate surgery the client is unconscious a

NCLEX-PN

Nclex PN Questions and Answers

1. The nurse in the emergency room is admitting a client who has sustained a gunshot wound and will require immediate surgery. The client is unconscious and by themselves. Which of the following actions is most appropriate?

A. Call the charge nurse and request that the facility's legal counsel provide a waiver for informed consent.
B. Attempt to stabilize the client in the emergency room until they are conscious enough to provide informed consent.
C. Try to locate the client's family to obtain informed consent before transporting the client to the operating room.
D. Proceed with transporting the client to the operating room without obtaining informed consent.

Correct answer: D

Rationale: In emergency situations where a client is unconscious and requires immediate surgery to save their life, the priority is to proceed with necessary interventions without delay to ensure the best possible outcome. Obtaining informed consent is essential in healthcare, but in situations where a delay in treatment can be life-threatening, healthcare providers are ethically and legally permitted to proceed with treatment without consent. Attempting to stabilize the client until conscious enough to provide consent or trying to locate family members for consent would cause a dangerous delay in critical care. Therefore, the most appropriate action in this scenario is to transport the unconscious client to the operating room for immediate surgery.

2. For a client requiring total oral care, it is important for the nurse to:

A. assemble all equipment, assist the client to a semi-Fowler's position, and place a towel on his chest.
B. place the client in Fowler's position, prepare the equipment, and instruct the client what to do.
C. assemble all equipment, place the client in a side-lying position, and place a towel under his chin.
D. use gloves and clean the client's mouth, including the tongue.

Correct answer: C

Rationale: To provide total oral care to a client, the nurse should first assemble all necessary equipment. Placing the client in a side-lying position helps fluids to easily flow out or pool in the side of the mouth for suctioning, thus preventing aspiration. Additionally, placing a towel under the client's chin and a curved basin against the chin helps to maintain cleanliness during the procedure. Choice A is incorrect because the client should be placed in a side-lying position, not a semi-Fowler's position which is used for respiratory issues. Choice B is incorrect as it does not emphasize the importance of proper positioning for effective oral care. Choice D is incorrect as it oversimplifies the procedure by focusing only on cleaning the mouth without considering the importance of positioning and preparation.

3. Which of the following statements to the client's family would be appropriate when preparing to provide postmortem care to the client?

A. "You will not be allowed to see your family member after the postmortem care is performed."?
B. "I am not able to assist you, but we can call pastoral care if you need any comfort."?
C. "Unfortunately, we are not allowed to incorporate any cultural practices in my preparations."?
D. "I will be ensuring that your family member is properly identified before they are transported."?

Correct answer: D

Rationale: The correct statement when preparing to provide postmortem care to the client's family is to assure them that the family member will be properly identified before transportation. This is crucial in ensuring the correct individual is being handled respectfully. Choices A, B, and C are incorrect as they do not address the essential aspect of ensuring the proper identification of the deceased before transportation. It is important to allow the family to see their loved one after postmortem care and, if possible, incorporate any cultural practices. Providing comfort and support to the family during this difficult time is also essential in delivering holistic care.

4. While preparing a client for a bronchoscopy, a nurse notes that the client is wearing a gold necklace. What should the nurse do to safeguard the client's necklace?

A. Ask the client for permission to lock the necklace in the hospital safe
B. Ask the client to remove the necklace and place it in the top drawer of the bedside table
C. Ask the client whether the necklace is gold
D. Ask the client to sign a release to free the hospital of responsibility if the necklace is damaged or lost during the procedure

Correct answer: A

Rationale: When a client has valuables such as jewelry, the nurse should ensure their safekeeping. It is appropriate for the nurse to ask the client for permission to lock the necklace in the hospital safe to prevent loss or damage. This option prioritizes the security of the necklace while allowing the client to make an informed decision. Asking the client to sign a release form does not guarantee the necklace's safety; it only releases the hospital from liability. Placing the necklace in a bedside table drawer does not provide adequate security as it is not as secure as a hospital safe. Inquiring whether the necklace is gold is irrelevant to safeguarding the jewelry during the procedure, as the primary concern is its safekeeping.

5. 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.