NCLEX-PN
Next Generation Nclex Questions Overview 3.0 ATI Quizlet
1. What is the role of the incident report in risk management?
- A. Liability protection.
- B. To provide data for analysis by a risk manager to determine how future problems can be avoided.
- C. To discipline staff for errors.
- D. All of the above.
Correct answer: B
Rationale: The correct answer is 'To provide data for analysis by a risk manager to determine how future problems can be avoided.' Incident reports are a crucial tool for collecting information about incidents to analyze them and prevent similar issues in the future. They are not primarily used for liability protection or disciplining staff. Therefore, choices A and C are incorrect. Selecting 'All of the above' (choice D) is not accurate as incident reports serve a specific purpose related to data analysis and risk prevention, excluding liability protection and staff discipline.
2. 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.
3. What is the most common cause of injury from a house fire?
- A. Explosion
- B. Falls from second-story windows
- C. Thermal damage to skin and body surfaces
- D. Inhalation injury
Correct answer: D
Rationale: Inhalation injury is the most common cause of injury from a house fire. When a fire occurs, the smoke produced contains harmful gases and particles that can be inhaled, leading to serious respiratory issues. This makes inhalation injury the primary concern during a house fire. Choices A, B, and C are less likely to be the primary cause of injury. While explosions may occur in some cases, inhalation of smoke and toxic fumes is generally the most prevalent danger. Falls from windows and thermal damage to the skin are also significant risks but typically occur after inhalation injuries in the sequence of events during a house fire.
4. A client with cirrhosis of the liver presents with ascites. The physician is to perform a paracentesis. For safety, the nurse should ask the client to:
- A. drink 1000 cc of fluid prior to the procedure to aid in fluid loss.
- B. eat foods low in fat.
- C. empty his bladder prior to the procedure.
- D. assume the prone position.
Correct answer: C
Rationale: When performing a paracentesis, the client must be sitting up to allow the fluid to settle in the lower abdomen. To prevent trauma to the bladder while inserting a needle to aspirate the fluid, the bladder must be empty. Choice A is incorrect as excessive fluid intake can make the procedure more difficult due to increased abdominal distension. Choice B is unrelated to the procedure of paracentesis. Choice D is incorrect as the client should be sitting up, not in the prone position, during the procedure.
5. The LPN is assisting the client with an NG tube with activities of daily living. Which of these statements would indicate a need for teaching reinforcement?
- A. "Since I'm not eating or drinking by mouth, I do not need to brush my teeth as often."?
- B. "I should remain sitting up at a 45-degree angle or higher for 30 minutes after a feeding."?
- C. "I can clean around the tube with water and mild soap."?
- D. "I should avoid using Vaseline around the nostril and tube."?
Correct answer: A
Rationale: The correct answer is, "Since I'm not eating or drinking by mouth, I do not need to brush my teeth as often."? This statement indicates a need for teaching reinforcement because even when an NG tube is in place, the client should still brush their teeth twice daily. Good oral hygiene is essential to reduce the risk of introducing bacteria that may cause an infection. Choice B is incorrect because remaining sitting up at a 45-degree angle or higher for 30 minutes after a feeding is a correct statement regarding NG tube care, promoting proper digestion and reducing the risk of aspiration. Choice C is also incorrect because cleaning around the tube with water and mild soap is an appropriate practice to maintain cleanliness and prevent infection. Choice D is incorrect because advising to avoid using Vaseline around the nostril and tube is a proper instruction to prevent skin breakdown, occlusion of the tube, and potential aspiration of Vaseline into the lungs.
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