NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. The client has a new prosthetic hip, and the nurse is repositioning them. Which position should be avoided to prevent injury to the new prosthetic hip?
- A. abduction of the hip
- B. adduction of the hip
- C.
- D.
Correct answer: B
Rationale: The correct answer is 'adduction of the hip.' When a client has a new prosthetic hip, adduction (movement of the leg toward the midline of the body) should be avoided to prevent injury to the new prosthetic hip. Abduction (movement of the leg away from the midline) is typically allowed and may even be encouraged. Flexing the hip at certain degrees is acceptable, but adduction should be avoided to prevent complications or dislocation of the prosthetic hip. Therefore, options A, C, and D are incorrect because they do not pose a direct risk to the new prosthetic hip compared to adduction.
2. 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.
3. What should be the primary action for a client who has just vomited 300 cc of bright red blood?
- A. Document the vomiting.
- B. Increase IV fluids.
- C. Get a complete blood count.
- D. Check the blood pressure.
Correct answer: D
Rationale: The correct first action for a client who has just vomited 300 cc of bright red blood is to check the blood pressure. This assessment is crucial to evaluate for hypotension, which could indicate significant blood loss and the need for immediate intervention. Documenting the vomiting is important for the client's medical record but not the initial priority. Increasing IV fluids and getting a complete blood count are necessary steps but should follow the assessment of the client's hemodynamic status.
4. Which of the following provides the framework for confidentiality and the client's right to privacy?
- A. Health Insurance Portability and Accountability Act
- B. CDC Surveillance Programs
- C. American Nurses Association Code of Ethics
- D. Durable Power of Attorney for Health Care
Correct answer: A
Rationale: The correct answer is the Health Insurance Portability and Accountability Act (HIPAA). HIPAA is the federal statute that outlines client confidentiality and the client's right to privacy. It establishes national standards to protect individuals' medical records and personal health information. The American Nurses Association Code of Ethics emphasizes principles of nursing ethics but does not serve as a legal framework for confidentiality and privacy. CDC Surveillance Programs focus on disease surveillance and control at a public health level and are not directly related to individual client privacy. The durable power of attorney for health care pertains to granting legal decision-making authority to another individual in healthcare matters, rather than addressing confidentiality and privacy rights.
5. Which of the following NSAIDs is most commonly used for a brief period for acute pain?
- A. Advil
- B. Aleve
- C. Toradol
- D. Bextra
Correct answer: C
Rationale: Toradol is the correct answer because it is an NSAID known for its effectiveness in managing acute pain for short durations. It can be administered via intramuscular (IM), intravenous (IV), or oral (PO) routes. Advil (choice A) and Aleve (choice B) are commonly used for mild to moderate pain but may not be as effective for acute pain requiring immediate relief. Bextra (choice D) was withdrawn from the market due to safety concerns, making it an inappropriate choice for acute pain management.
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