when the nurse is determining the appropriate size of an oropharyngeal airway to insert what part of a clients body should she measure

NCLEX-PN

Safe and Effective Care Environment Nclex PN Questions

1. When the nurse is determining the appropriate size of an oropharyngeal airway to insert, what part of a client's body should she 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: B

Rationale: Correct! When sizing an oropharyngeal airway, the nurse 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 reach the pharynx without being too long or too short. Choices B, C, and D are incorrect as they do not provide the correct anatomical landmarks for determining the size of an oropharyngeal airway. Measuring from the corner of the mouth to the tragus of the ear is a standard method to ensure proper airway size and prevent complications during airway management.

2. The LPN is auscultating for bowel sounds and hears between 3 and 4 bowel sounds per minute. This is a somewhat expected finding for which of these clients?

A. a 63-year-old female undergoing chemotherapy for breast cancer
B. a 56-year-old female with dementia undergoing a swallow study
C. a 34-year-old male with a PEG tube newly admitted for diabetic ketoacidosis
D. a 45-year-old male recovering from a knee replacement under general anesthesia

Correct answer: D

Rationale: When recovering from general anesthesia, hypoactive bowel sounds can be expected due to the effects of the anesthesia on gut motility. For the other clients, hearing less than 5 bowel sounds per minute would indicate an abnormal finding. In the context of the given situation, the client recovering from knee replacement surgery aligns with the expected range of bowel sounds post-general anesthesia. Therefore, choice D is the correct answer. Choices A, B, and C present scenarios where hearing less than 5 bowel sounds per minute would be abnormal, indicating potential issues that need further evaluation.

3. Which of the following isoenzymes is elevated in a client who has had a myocardial infarction?

A. CPK-BB
B. CPK-MM
C. CPK-MB
D. CPK-MI

Correct answer: C

Rationale: CPK-MB is the correct answer as it is elevated in clients who have had a myocardial infarction. CPK-BB is elevated in clients with brain damage, and CPK-MM is elevated in clients with skeletal muscle damage. CPK-MI, mentioned in the rationale, does not exist, making it an incorrect choice.

4. Which of the following tasks are appropriate for an LPN to perform?

A. Adjusting the cervical traction device of a 68-year-old client as instructed by the charge nurse.
B. performing operation on a woman in labour
C. Assessing a 36-year-old man newly admitted for chest pain.
D. Obtaining an occult blood sample from a 16-year-old client with ulcerative colitis.

Correct answer: D

Rationale: Tasks appropriate for an LPN to perform include teaching, obtaining samples, and documenting. LPNs can educate clients on care practices, such as teaching a new mother how to care for her baby. Obtaining samples, like an occult blood sample, falls within the scope of an LPN's responsibilities. Assessments, especially initial assessments, should be conducted by a registered nurse or physician, making option C incorrect. Adjusting devices like a cervical traction device should be done based on direct orders from prescribing providers, not charge nurses, making option A inappropriate for an LPN's role.

5. Which is the proper hand position for performing chest percussion?

A. Use the side of the hands
B. Flatten the hands
C. Spread the fingers of both hands
D. Cup the hands

Correct answer: D

Rationale: The proper hand position for performing chest percussion is to cup the hands. Cupping the hands helps produce a vibration that aids in loosening respiratory secretions effectively. This technique is essential for therapeutic chest physiotherapy. Using the side of the hands, flattening the hands, or spreading the fingers of both hands do not generate the necessary vibration required for chest percussion. These hand positions are not considered proper techniques in this context and may not provide the desired therapeutic effect.