NCLEX-PN
Safe and Effective Care Environment Nclex PN Questions
1. When should the biohazard emblem be affixed to containers according to the orientation nurse educator reviewing the biohazard legend with a class of new employees?
- A. when there is presence of blood and body fluids.
- B. when there is the need for droplet precautions.
- C. when there is contact isolation.
- D. when there is the potential for airborne transmission.
Correct answer: A
Rationale: The correct answer is 'when there is presence of blood and body fluids.' When handling body substances like blood and body fluids, the risk of transmission of infections increases. Federal regulations mandate warning labels on containers to alert employees and waste collectors. The biohazard emblem consists of a three-ring symbol overlaying a central concentric ring. Blood, wound drainage, feces, and urine are examples of body fluids that can transmit infections and diseases to others. The other choices, B, C, and D, are incorrect because the presence of the biohazard emblem is specifically linked to the handling of blood and body fluids, not to droplet precautions, contact isolation, or airborne transmission.
2. What is involved in client education by the nurse?
- A. Telling the client everything about their disease, what will happen in the course of the disease, and the outcome.
- B. Giving information to the client that is accurate and understandable.
- C. Informing the client that the pain they experience might not be real.
- D. Administering medication to the client when they experience pain.
Correct answer: B
Rationale: Client education by the nurse involves providing accurate and understandable information to the client. It is essential to offer relevant details without overwhelming them, making choice B the correct answer. Choice A is incorrect because providing excessive details can confuse the client rather than empower them with necessary knowledge. Choice C is incorrect as it is not the role of the nurse to question the reality of a client's pain; instead, they should address and manage the pain effectively. Choice D is incorrect as client education focuses on providing information and empowering clients with knowledge, not just administering medication.
3. When the healthcare provider is determining the appropriate size of an oropharyngeal airway to insert, what part of a client's body should they measure?
- A. corner of the mouth to the tragus of the ear
- B. corner of the eye to the top of the ear
- C. tip of the chin to the sternum
- D. tip of the nose to the earlobe
Correct answer: A
Rationale: When selecting the correct size of an oropharyngeal airway, the healthcare provider should measure from the corner of the client's mouth to the tragus of the ear. This measurement ensures that the airway is the appropriate length to maintain a clear air passage for exchange. Measuring from the corner of the eye to the top of the ear (Choice B) is inaccurate and not a standard measurement for selecting the size of an oropharyngeal airway. Measuring from the tip of the chin to the sternum (Choice C) is irrelevant to determining the correct size of the airway. Similarly, measuring from the tip of the nose to the earlobe (Choice D) is also incorrect and does not provide the necessary measurement for selecting an oropharyngeal airway size.
4. Ethical and moral issues concerning restraints include all of the following except:
- A. emotional impact on the client and family
- B. dignity of the client
- C. client's quality of life
- D. policies and procedures
Correct answer: D
Rationale: The correct answer is 'policies and procedures.' While policies and procedures are important for guidance and structure, they do not inherently involve ethical or moral considerations. The emotional impact on the client and family, the dignity of the client, and the client's quality of life are all directly related to ethical and moral concerns when it comes to the use of restraints. These factors are crucial in ensuring that the use of restraints is not only physically necessary but also ethically justifiable and respects the individual's rights and well-being. Therefore, options A, B, and C are all aspects that touch upon ethical and moral dimensions in the context of restraints.
5. While assisting a healthcare provider in assessing a hospitalized client, the healthcare provider is paged to report to the recovery room. The healthcare provider instructs the nurse verbally to change the solution and rate of the intravenous (IV) fluid being administered. What is the most appropriate nursing action in this situation?
- A. Calling the nursing supervisor to obtain permission to accept the verbal prescription
- B. Asking the healthcare provider to write the prescription in the client's record before leaving the nursing unit
- C. Telling the healthcare provider that the prescription will not be implemented until it is documented in the client's record
- D. Changing the solution and rate of the IV fluid per the healthcare provider's verbal prescription
Correct answer: B
Rationale: Verbal prescriptions should be avoided due to the risk of errors. If a verbal prescription is necessary, it should be promptly written and signed by the healthcare provider, typically within 24 hours. Following agency policies and procedures regarding verbal prescriptions is crucial. In this scenario, the most appropriate nursing action is to request the healthcare provider to document the prescription in the client's record before leaving the unit. Calling the nursing supervisor to accept the verbal prescription without documentation, telling the healthcare provider to delay treatment until documented, and directly changing the IV fluid based on verbal orders all pose risks and do not align with best practices in medication administration.
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