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 goals of palliative care include all of the following except:

A. giving clients with life-threatening illnesses the best quality of life possible.
B. taking care of the whole person"?body, mind, spirit, heart, and soul.
C. no interventions are needed because the client is near death.
D. supporting the needs of the family and client.

Correct answer: C

Rationale: The correct goal of palliative care is to provide comprehensive care that addresses the physical, emotional, social, and spiritual needs of the dying client until the end of life. Therefore, the statement 'no interventions are needed because the client is near death' is incorrect as interventions are still essential to ensure comfort and quality of life. Choices A, B, and D are all aligned with the goals of palliative care, focusing on improving the quality of life, providing holistic care, and supporting both the family and the client.

3. What does carrying a donor card for organ donation mean?

A. medical care is altered to obtain organs for donation in the event of serious injuries
B. the family or legally responsible party of a client has no decision-making authority in the event that the client is considered for organ donation
C. a client is allowed to revoke their decision for organ donation at any time
D. a client is considered an organ donor for multiple organs or tissues

Correct answer: C

Rationale: Carrying a donor card for organ donation signifies that an individual can decide to revoke their decision for organ donation at any point. This choice empowers the individual to change their mind regarding organ donation. The family or legally responsible party of a client still holds decision-making authority in the event that the client is considered for organ donation. When organ donation is being considered, all organs or tissues the donor wishes to donate are evaluated for donation suitability; it's not limited to just one organ or tissue. It's important to note that medical care for an individual is not altered to hasten the declaration of death for organ donation purposes; the focus is on providing immediate care and resuscitation to the individual.

4. An example of a process standard on a med-surg unit is:

A. a procedure for changing IV tubing.
B. a policy for staffing.
C. the job description of the CEO (chief executive officer).
D. a procedure for checking waveforms on a client being treated with an intra-aortic balloon pump.

Correct answer: D

Rationale: Process standards define the actions and behaviors required by staff to provide care on a med-surg unit. A procedure for changing IV tubing is a critical psychomotor skill necessary for safe and effective patient care in this setting. Choice B, a policy for staffing, pertains more to organizational management rather than specific care processes on the unit. Choice C, the job description of the CEO, delineates the responsibilities of the organization's top executive and is not a process standard for frontline staff. Choice D, a procedure for checking waveforms on a client with an intra-aortic balloon pump, is more specific to a cardiac care unit and not typically performed on a med-surg unit.

5. What instruction should a client who is about to undergo pelvic ultrasonography be given by a healthcare provider?

A. "Urinate prior to the test."?
B. "Have someone drive you home."?
C. "Do not drink after midnight."?
D. "Drink plenty of water."?

Correct answer: D

Rationale: The correct instruction for a client about to undergo pelvic ultrasonography is to 'Drink plenty of water.' A full bladder is required to serve as a landmark to define pelvic organs during the procedure. It is important to ensure the bladder is adequately filled. 'Urinate prior to the test' (Choice A) would not be appropriate as a full bladder is needed for better visualization. 'Have someone drive you home' (Choice B) is unnecessary as no sedation is given during the procedure, so the client can drive home on their own. 'Do not drink after midnight' (Choice C) is unrelated and not necessary for a pelvic ultrasonography examination.