which of the following devices may be applicable to a bedridden patient to address potential venous insufficiency choose all that apply a shear reduci
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Nursing Elites

NCLEX-PN

Safe and Effective Care Environment Nclex PN Questions

1. Which of the following devices may be applicable to a bedridden patient to address potential venous insufficiency?

Correct answer: B

Rationale: For a bedridden patient with potential venous insufficiency, sequential compression devices (SCDs) and compression stockings are appropriate choices. SCDs help improve venous return from the lower extremities by applying sequential pressure, aiding circulation. Compression stockings also assist in preventing blood from pooling in the legs by applying pressure to support venous return. Shear-reducing mattresses are not directly related to managing venous insufficiency, as they are designed to reduce friction and shear forces on the skin to prevent pressure ulcers. Non-skid socks are primarily used for fall prevention and have no direct impact on venous insufficiency.

2. 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?

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.

3. A nurse is planning to administer an oral antibiotic to a client with a communicable disease. The client refuses the medication and tells the nurse that the medication causes abdominal cramping. The nurse responds, 'The medication is needed to prevent the spread of infection, and if you don't take it orally I will have to give it to you in an intramuscular injection.' Which statement accurately describes the nurse's response to the client?

Correct answer: C

Rationale: The correct answer explains the concept of assault, which is an intentional threat to bring about harmful or offensive contact. In the scenario provided, the nurse's statement about administering the medication via an intramuscular injection without the client's consent constitutes a threat, potentially falling under the definition of assault. Choice A is incorrect because the nurse's action is not automatically justified solely by the client having a communicable disease. Choice D is also incorrect because even with a prescription, the nurse cannot administer the medication without the client's consent. Choice C provides a detailed explanation distinguishing assault from battery, which helps in understanding the legal implications of the nurse's response in this situation.

4. Following abdominal surgery, a client has a nasogastric (NG) tube in place. What is the purpose of this tube immediately after surgery?

Correct answer: C

Rationale: The correct answer is to prevent accumulation of fluids and gas. Immediately after abdominal surgery, the NG tube is used to keep the stomach decompressed, preventing the accumulation of fluids and gas. This helps in maintaining decompression to prevent surgical-site disruption and fluid loss through vomiting. Choices A, B, and D are incorrect because the primary purpose of the NG tube following abdominal surgery is to prevent complications related to fluid and gas build-up rather than simplifying medication administration, measuring input and output, or collecting specimens.

5. Which of these statements is true regarding advance directives?

Correct answer: D

Rationale: The correct statement is that advance directives cannot be honored by EMTs unless they are signed by a doctor. EMTs are required to provide emergency care to a client, irrespective of their advance directive status, unless the directive has been signed by a doctor. When a client is brought to the hospital, physicians will assess the client and implement the advance directive if necessary. Advance directives do not need to be reviewed and re-signed every 10 years to remain valid; they remain in effect until changed. While advance directives are legally valid in most states, some states may not honor those created in other states, so it's advisable to check the new state's policies if a client moves. Additionally, it typically requires two physicians, not just one, to determine if a client is unable to make medical decisions for themselves.

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